Provider Demographics
NPI:1619081692
Name:WAMEGO DRUG STORE INC
Entity Type:Organization
Organization Name:WAMEGO DRUG STORE INC
Other - Org Name:WAMEGO DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-456-9292
Mailing Address - Street 1:PO BOX 227
Mailing Address - Street 2:
Mailing Address - City:WAMEGO
Mailing Address - State:KS
Mailing Address - Zip Code:66547-0227
Mailing Address - Country:US
Mailing Address - Phone:785-456-9292
Mailing Address - Fax:
Practice Address - Street 1:501 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WAMEGO
Practice Address - State:KS
Practice Address - Zip Code:66547-1633
Practice Address - Country:US
Practice Address - Phone:785-456-9292
Practice Address - Fax:785-456-9628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
KS2092863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100443920BMedicaid
2031269OtherPK
KS100443920BMedicaid