Provider Demographics
NPI:1225127152
Name:WELLCARE PHARMACY INC
Entity Type:Organization
Organization Name:WELLCARE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT/PHARMACY MGR
Authorized Official - Prefix:DR
Authorized Official - First Name:TEMITOPE
Authorized Official - Middle Name:OULWAYEMISI
Authorized Official - Last Name:GBOLAGUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-654-4441
Mailing Address - Street 1:9213 LAKESIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3859
Mailing Address - Country:US
Mailing Address - Phone:410-654-4441
Mailing Address - Fax:410-654-4463
Practice Address - Street 1:9213 LAKESIDE BLVD
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3859
Practice Address - Country:US
Practice Address - Phone:410-654-4441
Practice Address - Fax:410-654-4463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP04406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5681090001Medicare NSC