Provider Demographics
NPI:1245576685
Name:PHARMCLINIC TWO LLC
Entity Type:Organization
Organization Name:PHARMCLINIC TWO LLC
Other - Org Name:WELLNESS AND WEIGHTLOSS OF TAMPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-293-8459
Mailing Address - Street 1:1116 N FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-1710
Mailing Address - Country:US
Mailing Address - Phone:850-683-1111
Mailing Address - Fax:850-683-1753
Practice Address - Street 1:1135 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4887
Practice Address - Country:US
Practice Address - Phone:813-689-9911
Practice Address - Fax:813-653-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service