Healthcare Provider Details

I. General information

NPI: 1306958251
Provider Name (Legal Business Name): WYCLIFF PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10410 MASTIN ST
OVERLAND PARK KS
66212-5701
US

IV. Provider business mailing address

10410 MASTIN ST
OVERLAND PARK KS
66212-5701
US

V. Phone/Fax

Practice location:
  • Phone: 913-492-4998
  • Fax: 913-492-5121
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number208444
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DENA FERMAN
Title or Position: THIRD PARTY PLAN COORDINATOR
Credential:
Phone: 314-993-6000