Healthcare Provider Details

I. General information

NPI: 1306239538
Provider Name (Legal Business Name): PRESTON PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2622 W CENTRAL AVE STE 302
WICHITA KS
67203-4973
US

IV. Provider business mailing address

2622 W CENTRAL AVE STE 302
WICHITA KS
67203-4973
US

V. Phone/Fax

Practice location:
  • Phone: 316-265-3300
  • Fax: 316-265-3304
Mailing address:
  • Phone: 316-265-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-12291
License Number StateKS

VIII. Authorized Official

Name: LEW R ENNS
Title or Position: STAFF/CONSULTING PHARMACIST
Credential: RPH
Phone: 316-265-3300