Provider Demographics
NPI:1972664837
Name:J. RUTOWSKI OF WANAKAH INC.
Entity Type:Organization
Organization Name:J. RUTOWSKI OF WANAKAH INC.
Other - Org Name:WANAKAH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SP
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:RUTOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-627-3232
Mailing Address - Street 1:4923 LAKE SHORE RD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5662
Mailing Address - Country:US
Mailing Address - Phone:716-627-3232
Mailing Address - Fax:716-627-5018
Practice Address - Street 1:4923 LAKE SHORE RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-5662
Practice Address - Country:US
Practice Address - Phone:716-627-3232
Practice Address - Fax:716-627-5018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0241973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01934041Medicaid
NY01934041Medicaid