Provider Demographics
NPI:1811011620
Name:WELLCARE PHARMACY & HOME INFUSION LLC
Entity Type:Organization
Organization Name:WELLCARE PHARMACY & HOME INFUSION LLC
Other - Org Name:WELLCARE PHARMACY & MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:KAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-9990
Mailing Address - Street 1:4160 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2050
Mailing Address - Country:US
Mailing Address - Phone:318-212-9990
Mailing Address - Fax:318-212-9993
Practice Address - Street 1:4160 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2050
Practice Address - Country:US
Practice Address - Phone:318-212-9990
Practice Address - Fax:318-212-9993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1235679332B00000X
6168-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1235679Medicaid