Provider Demographics
NPI:1396849352
Name:WINDHAM PHARMACY INC
Entity Type:Organization
Organization Name:WINDHAM PHARMACY INC
Other - Org Name:WINDHAM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:SWIPAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-326-3851
Mailing Address - Street 1:9650 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:OH
Mailing Address - Zip Code:44288-1050
Mailing Address - Country:US
Mailing Address - Phone:330-326-3851
Mailing Address - Fax:330-326-2995
Practice Address - Street 1:9650 E CENTER ST
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:OH
Practice Address - Zip Code:44288-1050
Practice Address - Country:US
Practice Address - Phone:330-326-3851
Practice Address - Fax:330-326-2995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0201791003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3615993OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH0471467Medicaid
3615993OtherNCPDP PROVIDER IDENTIFICATION NUMBER