Provider Demographics
NPI:1417290008
Name:WELLCARE PHARMACY LLC
Entity Type:Organization
Organization Name:WELLCARE PHARMACY LLC
Other - Org Name:WELLCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VARGHESE NELLIKUNNAT
Authorized Official - Middle Name:
Authorized Official - Last Name:VARKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-263-5050
Mailing Address - Street 1:4200 SOUTH FWY STE 26
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-1400
Mailing Address - Country:US
Mailing Address - Phone:817-263-5050
Mailing Address - Fax:817-263-5020
Practice Address - Street 1:4200 SOUTH FWY STE 26
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-1400
Practice Address - Country:US
Practice Address - Phone:817-263-5050
Practice Address - Fax:817-263-5020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-01
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX284933336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146771Medicaid
2139768OtherPK