Provider Demographics
NPI:1528573623
Name:WELLNESS PHARMACY AND COMPOUNDING CENTER LLC
Entity Type:Organization
Organization Name:WELLNESS PHARMACY AND COMPOUNDING CENTER LLC
Other - Org Name:WELLNESS PHARMACY AND COMPOUND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TED JEFFERSON
Authorized Official - Middle Name:BOYLAN
Authorized Official - Last Name:SINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-964-5656
Mailing Address - Street 1:2601 BLUE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-0111
Mailing Address - Country:US
Mailing Address - Phone:919-964-5656
Mailing Address - Fax:919-964-5757
Practice Address - Street 1:2601 BLUE RIDGE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607
Practice Address - Country:US
Practice Address - Phone:919-413-2120
Practice Address - Fax:919-964-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC134223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1528573623Medicaid