Healthcare Provider Details

I. General information

NPI: 1083655765
Provider Name (Legal Business Name): BRUNDAGES WAYMART PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 BELMONT ST
WAYMART PA
18472-9310
US

IV. Provider business mailing address

PO BOX 398
WAYMART PA
18472-0398
US

V. Phone/Fax

Practice location:
  • Phone: 570-488-7979
  • Fax: 570-488-7773
Mailing address:
  • Phone: 570-488-7979
  • Fax: 570-488-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP415770L
License Number StatePA

VIII. Authorized Official

Name: MICHAEL BRUNDAGE
Title or Position: PRESIDENT PHARMACY MANAGER
Credential: PHARM D
Phone: 570-488-7979