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Provider Information for 1811908320


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WAYLAND VILLAGE DRUG INC

Other Names:  
Doing Business As: 
WAYLAND VILLAGE PHARMACY

Organization Subpart: NO

NPI: 1811908320
Last Updated: 2016-06-16
Certification Date:

Details

NameValue
NPI1811908320
Enumeration Date2006-08-10
NPI TypeNPI-2 Organization
StatusActive
Authorized Official Information Name: MICHEAL SHEA B.S. Pharmacy
Title: OWNER
Phone: 2697926223
Mailing Address 300 RENO DR
WAYLAND, MI 49348-1277
United States

Phone: 269-792-6223 | Fax:269-792-6349
 
Primary Practice Address 300 RENO DR
WAYLAND, MI 49348-1277
United States

Phone: 269-792-6223 | Fax:269-792-6349
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDMI1758774
Other (non-Medicare)2039491PK
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 333600000X - Pharmacy
Yes 3336C0003X - Pharmacy - Community/Retail PharmacyMI5301004420