=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962435016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESCLARE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 MEMORIAL BLVD
-----------------------------------------------------
City | CONNELLSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15425-2653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-628-8125
-----------------------------------------------------
Fax | 724-628-5727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 NICKMAN'S PLAZA
-----------------------------------------------------
City | LEMONT FURNACE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-437-2144
-----------------------------------------------------
Fax | 724-437-8303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JAMES WESLEY NICKMAN JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 724-437-2144
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP481096
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------