Provider Demographics
NPI:1548759095
Name:WEST FAYETTE DRUGS LLC
Entity Type:Organization
Organization Name:WEST FAYETTE DRUGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALLIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-678-8459
Mailing Address - Street 1:713A W FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:713A W FAYETTE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2902
Practice Address - Country:US
Practice Address - Phone:732-678-8459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies