Provider Demographics
NPI:1790054773
Name:WELLS PHARMACY NETWORK LLC
Entity Type:Organization
Organization Name:WELLS PHARMACY NETWORK LLC
Other - Org Name:WELLS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILBUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-793-1568
Mailing Address - Street 1:11120 S CROWN WAY
Mailing Address - Street 2:SUITE 11
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8718
Mailing Address - Country:US
Mailing Address - Phone:561-793-1568
Mailing Address - Fax:561-793-1570
Practice Address - Street 1:11120 S CROWN WAY STE 11
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-8718
Practice Address - Country:US
Practice Address - Phone:561-793-1568
Practice Address - Fax:561-793-1570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
FLPH257993336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5708435OtherNCPDP PROVIDER IDENTIFICATION NUMBER