Provider Demographics
NPI:1598431991
Name:THE WIG DISPENSARY
Entity Type:Organization
Organization Name:THE WIG DISPENSARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAZMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BADIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-335-2243
Mailing Address - Street 1:1070 MONTGOMERY RD # 2351
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7420
Mailing Address - Country:US
Mailing Address - Phone:407-619-6827
Mailing Address - Fax:407-906-9364
Practice Address - Street 1:1070 MONTGOMERY RD
Practice Address - Street 2:STE 2351
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-7420
Practice Address - Country:US
Practice Address - Phone:407-619-6827
Practice Address - Fax:407-906-9364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier