Provider Demographics
NPI:1508921800
Name:WALDRON PHARMACY, INC.
Entity Type:Organization
Organization Name:WALDRON PHARMACY, INC.
Other - Org Name:WALDRONS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:620-492-3263
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:JOHNSON
Mailing Address - State:KS
Mailing Address - Zip Code:67855-0579
Mailing Address - Country:US
Mailing Address - Phone:620-492-3263
Mailing Address - Fax:620-492-3318
Practice Address - Street 1:111 S MAIN
Practice Address - Street 2:
Practice Address - City:JOHNSON
Practice Address - State:KS
Practice Address - Zip Code:67855
Practice Address - Country:US
Practice Address - Phone:620-492-3263
Practice Address - Fax:620-492-3318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
KS2093283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2026864OtherPK
KS200419060AMedicaid
CO25808729Medicaid