Provider Demographics
NPI:1710990676
Name:15W PHARMACY NY LLC
Entity Type:Organization
Organization Name:15W PHARMACY NY LLC
Other - Org Name:THE WELLMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPS
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELMART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-897-2905
Mailing Address - Street 1:95 NEWFIELD AVE
Mailing Address - Street 2:STE B
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-3824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 WESTAGE BUSINESS CTR DR
Practice Address - Street 2:STE 119
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-2264
Practice Address - Country:US
Practice Address - Phone:845-897-2905
Practice Address - Fax:845-897-2908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336C0004X, 3336H0001X, 3336S0011X
NY027728332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Not Answered3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Not Answered3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02803689Medicaid
3351828OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY02803689Medicaid