MEDICARE: WILEYS PHARMACY & COMPOUNDING SERVICE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	PHY006288IR	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1935266	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1386950707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILEYS PHARMACY & COMPOUNDING SERVICE INC

Provider Business Mailing Address
First Line	:	2403 ARKANSAS RD
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71291-8611
Country	:	US
Telephone Number	:	318-396-1812
Fax Number	:	318-396-5602

Provider Business Practice Location Address
First Line	:	2933 CYPRESS ST STE 2
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71291-5337
Country	:	US
Telephone Number	:	318-396-1812
Fax Number	:	318-396-5602

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOSEPH WILEY
Credential	:
Telephone Number	:	318-396-1812

Provider Enumeration Date	:	08/23/2010
Last Update Date	:	12/06/2010

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