Provider Demographics
NPI:1942211453
Name:WASCO VALLEY PHARMACY INC
Entity Type:Organization
Organization Name:WASCO VALLEY PHARMACY INC
Other - Org Name:WASCO MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LWENYA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:661-758-1123
Mailing Address - Street 1:PO BOX 1257
Mailing Address - Street 2:
Mailing Address - City:WASCO
Mailing Address - State:CA
Mailing Address - Zip Code:93280-8157
Mailing Address - Country:US
Mailing Address - Phone:661-758-1123
Mailing Address - Fax:661-759-2800
Practice Address - Street 1:1129 7TH ST
Practice Address - Street 2:
Practice Address - City:WASCO
Practice Address - State:CA
Practice Address - Zip Code:93280-1819
Practice Address - Country:US
Practice Address - Phone:661-758-1123
Practice Address - Fax:661-759-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336H0001X, 3336S0011X
CAPHY470903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5615325OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA470900Medicaid
5615325OtherNCPDP PROVIDER IDENTIFICATION NUMBER