Provider Demographics
NPI:1407440290
Name:ST.CLOUD PHARMACY&WELLNESS CENTER
Entity Type:Organization
Organization Name:ST.CLOUD PHARMACY&WELLNESS CENTER
Other - Org Name:ST CLOUD COMPOUNDING PHARMACY & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SIBY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PUTHENPURAYIL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:407-593-2959
Mailing Address - Street 1:2801 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4134
Mailing Address - Country:US
Mailing Address - Phone:407-593-2959
Mailing Address - Fax:407-593-2957
Practice Address - Street 1:2801 13TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4134
Practice Address - Country:US
Practice Address - Phone:407-593-2959
Practice Address - Fax:407-593-2957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-23
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy