Provider Demographics
NPI:1508453077
Name:PROGRESSIVE WELLNESS PHARMACY LLC
Entity Type:Organization
Organization Name:PROGRESSIVE WELLNESS PHARMACY LLC
Other - Org Name:PROGRESSIVE WELLNESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:HUSSEIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIDAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:419-540-9988
Mailing Address - Street 1:7640 SYLVANIA AVE STE C-1
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7640 SYLVANIA AVE STE C-1
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-9263
Practice Address - Country:US
Practice Address - Phone:419-749-3193
Practice Address - Fax:419-299-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy