Provider Demographics
NPI:1548737182
Name:WEST WICHITA FAMILY PHARMACY LLC
Entity Type:Organization
Organization Name:WEST WICHITA FAMILY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DARRAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-491-6481
Mailing Address - Street 1:8200 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-9503
Mailing Address - Country:US
Mailing Address - Phone:316-491-6428
Mailing Address - Fax:316-512-4001
Practice Address - Street 1:8200 W CENTRAL AVE STE 5
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-3661
Practice Address - Country:US
Practice Address - Phone:316-491-6428
Practice Address - Fax:316-512-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-01
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201270110AMedicaid