Provider Demographics
NPI:1770684557
Name:CANDLEWOOD PHARMACY, LC
Entity Type:Organization
Organization Name:CANDLEWOOD PHARMACY, LC
Other - Org Name:CANDLEWOOD HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HELLERICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:785-776-4100
Mailing Address - Street 1:3254 KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-2157
Mailing Address - Country:US
Mailing Address - Phone:785-776-4100
Mailing Address - Fax:785-776-1039
Practice Address - Street 1:3254 KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-2157
Practice Address - Country:US
Practice Address - Phone:785-776-4100
Practice Address - Fax:785-776-1039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2-09136313M00000X, 3336C0003X, 3336L0003X, 3336L0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100325350AMedicaid