Provider Demographics
NPI:1013322353
Name:WYOMING DISCOUNT PHARMACY LLC
Entity Type:Organization
Organization Name:WYOMING DISCOUNT PHARMACY LLC
Other - Org Name:WYOMING DISCOUNT PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-341-8888
Mailing Address - Street 1:18200 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2032
Mailing Address - Country:US
Mailing Address - Phone:313-341-8888
Mailing Address - Fax:313-342-8888
Practice Address - Street 1:18200 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2032
Practice Address - Country:US
Practice Address - Phone:313-341-8888
Practice Address - Fax:313-342-8888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010105563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147661OtherPK