MEDICARE: YOUR NEW WAVERLY PHARMACY LLC

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	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	28286	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5907273	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1912250507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUR NEW WAVERLY PHARMACY LLC

Provider Business Mailing Address
First Line	:	PO BOX 1610
Second Line	:
City	:	NEW WAVERLY
State	:	TX
Zip	:	77358-1610
Country	:	US
Telephone Number	:	936-344-2424
Fax Number	:	936-344-2428

Provider Business Practice Location Address
First Line	:	9320C STATE HIGHWAY 75 S
Second Line	:
City	:	NEW WAVERLY
State	:	TX
Zip	:	77358-4224
Country	:	US
Telephone Number	:	936-344-2424
Fax Number	:	936-344-2428

Authorized Official
Title or Position	:	PHARMACIST IN CHARGE
Name	:	BILL WILT
Credential	:
Telephone Number	:	281-804-3234

Provider Enumeration Date	:	10/19/2012
Last Update Date	:	10/19/2020

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