Provider Demographics
NPI:1023200441
Name:WELVISTA
Entity Type:Organization
Organization Name:WELVISTA
Other - Org Name:WELVISTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-933-9183
Mailing Address - Street 1:2700 MIDDLEBURG DR STE 108
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2416
Mailing Address - Country:US
Mailing Address - Phone:803-933-9183
Mailing Address - Fax:803-254-0892
Practice Address - Street 1:2700 MIDDLEBURG DR STE 108
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2416
Practice Address - Country:US
Practice Address - Phone:803-933-9183
Practice Address - Fax:803-254-0892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC102193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093414OtherPK
SC710219Medicaid