Provider Demographics
NPI:1376040683
Name:AUSTIN WELLNESS PHARMACY, LLC
Entity Type:Organization
Organization Name:AUSTIN WELLNESS PHARMACY, LLC
Other - Org Name:AUSTIN WELLNESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:CADDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-877-2536
Mailing Address - Street 1:6902 AUSTIN ST
Mailing Address - Street 2:SUITE G3
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4233
Mailing Address - Country:US
Mailing Address - Phone:718-263-6688
Mailing Address - Fax:718-263-6690
Practice Address - Street 1:6902 AUSTIN ST STE G3
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4250
Practice Address - Country:US
Practice Address - Phone:718-263-6688
Practice Address - Fax:718-263-6690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0329773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176863OtherPK
NY4050804Medicaid