Provider Demographics
NPI:1275108227
Name:WELLCARE OF HOUSTON GROUP, LLC
Entity Type:Organization
Organization Name:WELLCARE OF HOUSTON GROUP, LLC
Other - Org Name:WELLCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER MANAGED
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:408-661-3881
Mailing Address - Street 1:17515 SPRING CYPRESS RD # 256
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-2688
Mailing Address - Country:US
Mailing Address - Phone:408-661-3881
Mailing Address - Fax:
Practice Address - Street 1:14343 TORREY CHASE BLVD STE I
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77014-1630
Practice Address - Country:US
Practice Address - Phone:408-661-3881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-21
Last Update Date:2022-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy