Provider Demographics
NPI:1770174476
Name:BROWN, WAYLON
Entity type:Individual
Prefix:
First Name:WAYLON
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 APPLE TREE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT WOLF
Mailing Address - State:PA
Mailing Address - Zip Code:17347-9009
Mailing Address - Country:US
Mailing Address - Phone:717-819-2906
Mailing Address - Fax:
Practice Address - Street 1:723 LOMBARD RD
Practice Address - Street 2:
Practice Address - City:RED LION
Practice Address - State:PA
Practice Address - Zip Code:17356-8396
Practice Address - Country:US
Practice Address - Phone:717-244-4501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10558183500000X
MT4351183500000X
PA445474183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist