Provider Demographics
NPI:1376167908
Name:WANDAROO INC
Entity Type:Organization
Organization Name:WANDAROO INC
Other - Org Name:THE HOMETOWN PHARMACY LONG TERM CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:330-318-3926
Mailing Address - Street 1:8571 FOXWOOD CT STE A
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-4313
Mailing Address - Country:US
Mailing Address - Phone:330-318-3926
Mailing Address - Fax:330-318-3927
Practice Address - Street 1:1135 W WESTERN RESERVE RD
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-3592
Practice Address - Country:US
Practice Address - Phone:330-629-7345
Practice Address - Fax:330-629-7353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-29
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2960005Medicaid