Provider Demographics
NPI:1760798359
Name:WALNUT STREET APOTHECARY INC
Entity Type:Organization
Organization Name:WALNUT STREET APOTHECARY INC
Other - Org Name:WYNNEFIELD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-247-4122
Mailing Address - Street 1:1006 W LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133-1640
Mailing Address - Country:US
Mailing Address - Phone:215-225-7522
Mailing Address - Fax:215-225-7525
Practice Address - Street 1:1901 N 54TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-3221
Practice Address - Country:US
Practice Address - Phone:215-222-2400
Practice Address - Fax:215-222-2442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4820553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3994274OtherNCPDP PROVIDER IDENTIFICATION NUMBER