Provider Demographics
NPI:1598845604
Name:WILEYS PHARMACY AND COMPOUNDING SERVICE INC
Entity Type:Organization
Organization Name:WILEYS PHARMACY AND COMPOUNDING SERVICE INC
Other - Org Name:MASONS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-396-1812
Mailing Address - Street 1:2403 ARKANSAS RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-8611
Mailing Address - Country:US
Mailing Address - Phone:318-396-1812
Mailing Address - Fax:318-396-5602
Practice Address - Street 1:2403 ARKANSAS RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-8611
Practice Address - Country:US
Practice Address - Phone:318-396-1812
Practice Address - Fax:318-396-5602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPHY.005903-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1916090OtherNCPDP PROVIDER IDENTIFICATION NUMBER
LA1250571Medicaid
1079810001Medicare NSC