Provider Demographics
NPI:1902253214
Name:WYODAK PHARMACIES INC
Entity Type:Organization
Organization Name:WYODAK PHARMACIES INC
Other - Org Name:VILAS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:605-224-4538
Mailing Address - Street 1:145 GLENDALE DR
Mailing Address - Street 2:
Mailing Address - City:LEAD
Mailing Address - State:SD
Mailing Address - Zip Code:57754
Mailing Address - Country:US
Mailing Address - Phone:605-717-2496
Mailing Address - Fax:605-717-2497
Practice Address - Street 1:145 GLENDALE DR
Practice Address - Street 2:
Practice Address - City:LEAD
Practice Address - State:SD
Practice Address - Zip Code:57754
Practice Address - Country:US
Practice Address - Phone:605-717-2496
Practice Address - Fax:605-717-2497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD100-20423336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1902253214Medicaid
2160047OtherPK