Provider Demographics
NPI:1932231537
Name:WEDGEWOOD VILLAGE PHARMACY LLC
Entity Type:Organization
Organization Name:WEDGEWOOD VILLAGE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-832-1303
Mailing Address - Street 1:405 HERON DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SWEDESBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-1749
Mailing Address - Country:US
Mailing Address - Phone:800-331-8272
Mailing Address - Fax:856-589-5176
Practice Address - Street 1:405 HERON DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SWEDESBORO
Practice Address - State:NJ
Practice Address - Zip Code:08085-1749
Practice Address - Country:US
Practice Address - Phone:800-331-8272
Practice Address - Fax:856-589-5176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS003168003336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy