Provider Demographics
NPI:1417354085
Name:JOHN WAYNE PHARMACY LLC
Entity Type:Organization
Organization Name:JOHN WAYNE PHARMACY LLC
Other - Org Name:PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:VANWIE
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:410-687-8113
Mailing Address - Street 1:9106 PHILADELPHIA ROAD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237
Mailing Address - Country:US
Mailing Address - Phone:410-687-8113
Mailing Address - Fax:410-391-3922
Practice Address - Street 1:9106 PHILADELPHIA ROAD
Practice Address - Street 2:SUITE #100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237
Practice Address - Country:US
Practice Address - Phone:410-687-8113
Practice Address - Fax:410-391-3922
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN WAYNE PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD11499183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD700301300Medicaid
MD5917720001Medicare UPIN