1265083729 NPI number — WELLDYNERX, LLC

Table of content: (NPI 1265083729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265083729 NPI number — WELLDYNERX, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLDYNERX, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265083729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 EAGLES LANDING DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33810-2899
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-583-6523
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 EAGLES LANDING DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33810-2899
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-583-6523
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
FLEISCHMAN
Authorized Official First Name:
JOE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
863-583-6063

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1024462370001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1093974982 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20029370A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200972230A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100080584 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200636740A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000170493 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03285290 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20200323899433 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1017697 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001055000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0205365 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1093974982 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1093974982 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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