Provider Demographics
NPI:1033296900
Name:FITWEL PHARMACY LLC
Entity Type:Organization
Organization Name:FITWEL PHARMACY LLC
Other - Org Name:MEDICINE TO GO PHARMACIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRIDEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:VAJINEPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-367-5222
Mailing Address - Street 1:1000 ROUTE 70
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5961
Mailing Address - Country:US
Mailing Address - Phone:732-367-5222
Mailing Address - Fax:732-367-3393
Practice Address - Street 1:1000 ROUTE 70
Practice Address - Street 2:SUITE 7
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5961
Practice Address - Country:US
Practice Address - Phone:732-367-5222
Practice Address - Fax:732-367-3393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS006472003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167441OtherPK
NJ0577251Medicaid
NJ0065595Medicaid