Provider Demographics
NPI:1912988270
Name:WRINKLE'S PHARMACY, INC.
Entity Type:Organization
Organization Name:WRINKLE'S PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-238-4522
Mailing Address - Street 1:6210 NW COGDILL RD
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64463-9247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5409 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64504-1439
Practice Address - Country:US
Practice Address - Phone:816-238-4522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-12
Last Update Date:2016-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002729333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2603074OtherNABP/NACDS
0254570001Medicare ID - Type UnspecifiedMEDICARE PROVIDER