Provider Demographics
NPI:1629089289
Name:WOODMARK PHARMACY
Entity Type:Organization
Organization Name:WOODMARK PHARMACY
Other - Org Name:WOODMARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-631-3381
Mailing Address - Street 1:1142 WEHRLE DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7748
Mailing Address - Country:US
Mailing Address - Phone:716-631-3381
Mailing Address - Fax:716-631-3097
Practice Address - Street 1:1142 WEHRLE DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7748
Practice Address - Country:US
Practice Address - Phone:716-631-3381
Practice Address - Fax:716-631-3097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0318693336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01572590Medicaid
2063513OtherPK