Provider Demographics
NPI:1811201452
Name:WELLNESS PHARMACY INC
Entity Type:Organization
Organization Name:WELLNESS PHARMACY INC
Other - Org Name:WELLNESS PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:GASHAW
Authorized Official - Middle Name:
Authorized Official - Last Name:ADANE
Authorized Official - Suffix:
Authorized Official - Credentials:BPHARM
Authorized Official - Phone:813-408-4097
Mailing Address - Street 1:120 W BOUGAINVILLEA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-7437
Mailing Address - Country:US
Mailing Address - Phone:813-774-8856
Mailing Address - Fax:813-319-3760
Practice Address - Street 1:120 W BOUGAINVILLEA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-7437
Practice Address - Country:US
Practice Address - Phone:813-774-8856
Practice Address - Fax:813-319-3760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X, 3336L0003X, 3336M0002X, 3336M0003X, 3336S0011X, 3336C0004X
FLPH246653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126001OtherPK
FL002872100Medicaid