Provider Demographics
NPI:1619097961
Name:WADHAMS APOTHECARY INC
Entity Type:Organization
Organization Name:WADHAMS APOTHECARY INC
Other - Org Name:WADHAMS APOTHECARY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:WADHAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:928-774-5004
Mailing Address - Street 1:3100 N WEST ST STE 200A
Mailing Address - Street 2:STE 200A
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1651
Mailing Address - Country:US
Mailing Address - Phone:928-774-5004
Mailing Address - Fax:928-774-5003
Practice Address - Street 1:3100 N WEST ST STE 200A
Practice Address - Street 2:STE 200A
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1651
Practice Address - Country:US
Practice Address - Phone:928-774-5004
Practice Address - Fax:928-774-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
AZY0047353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ204681Medicaid
1989418OtherPK