Provider Demographics
NPI:1780194415
Name:YOUR WELLNESS PHARMACY CORP
Entity Type:Organization
Organization Name:YOUR WELLNESS PHARMACY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABISMAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:QUILES SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-880-0000
Mailing Address - Street 1:12614 MERRICK BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12614 MERRICK BLVD STE F
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3431
Practice Address - Country:US
Practice Address - Phone:718-880-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy