Provider Demographics
NPI:1811902414
Name:DANAURA ENTERPRISES
Entity type:Organization
Organization Name:DANAURA ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD OWNER RPH
Authorized Official - Phone:412-486-4588
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:2506 WILDWOOD ROAD
Mailing Address - City:WILDWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:15091
Mailing Address - Country:US
Mailing Address - Phone:412-486-4588
Mailing Address - Fax:412-486-4898
Practice Address - Street 1:2506 WILDWOOD ROAD
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:PA
Practice Address - Zip Code:15091
Practice Address - Country:US
Practice Address - Phone:412-486-4588
Practice Address - Fax:412-486-4898
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DANAURA ENTERPRISES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-30
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336L0003X
PAPP415155L3336L0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0130840001Medicaid
3971428OtherOTHER ID NUMBER-COMMERCIAL NUMBER
PA0130840001Medicaid