Provider Demographics
NPI:1497809792
Name:WAYLAND APOTHECARY
Entity Type:Organization
Organization Name:WAYLAND APOTHECARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:508-665-2828
Mailing Address - Street 1:302 COMMONWEALTH RD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-5006
Mailing Address - Country:US
Mailing Address - Phone:508-655-2828
Mailing Address - Fax:508-650-9052
Practice Address - Street 1:302 COMMONWEALTH RD
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-5006
Practice Address - Country:US
Practice Address - Phone:508-655-2828
Practice Address - Fax:508-650-9052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0434116Medicaid