MEDICARE: WILDERNESS CENTER PHARMACY INC

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	183500000X	Pharmacist	0201002108	VA

General Provider Information

NPI Number	:	1316941024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILDERNESS CENTER PHARMACY INC

Provider Business Mailing Address
First Line	:	5479 GERMANNA HWY
Second Line	:
City	:	LOCUST GROVE
State	:	VA
Zip	:	22508-2018
Country	:	US
Telephone Number	:	540-972-7994
Fax Number	:	540-972-0706

Provider Business Practice Location Address
First Line	:	5479 GERMANNA HWY
Second Line	:
City	:	LOCUST GROVE
State	:	VA
Zip	:	22508-2018
Country	:	US
Telephone Number	:	540-972-7994
Fax Number	:	540-972-0706

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. EUGENE FRENCH TRIPLETT JR.
Credential	:	R.PH
Telephone Number	:	540-972-7994

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	08/22/2020

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