Provider Demographics
NPI:1497829923
Name:WRIGHT STATE UNIVERSITY PHARMACY
Entity Type:Organization
Organization Name:WRIGHT STATE UNIVERSITY PHARMACY
Other - Org Name:FREDERICK WHITE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOC DEAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:937-775-3182
Mailing Address - Street 1:3817 UNIVERSITY PARK
Mailing Address - Street 2:BSOM BUSINESS OFFICE
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45435-0001
Mailing Address - Country:US
Mailing Address - Phone:937-775-3414
Mailing Address - Fax:937-775-2167
Practice Address - Street 1:3640 COLONEL GLENN HWY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45435-0001
Practice Address - Country:US
Practice Address - Phone:937-775-3414
Practice Address - Fax:937-775-2167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2009-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0202915003336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00581651Medicaid
3641138OtherNCPDP PROVIDER IDENTIFICATION NUMBER