Provider Demographics
NPI:1902202898
Name:WELLNESS PHARMACY OF ST AUGUSTINE LLC
Entity Type:Organization
Organization Name:WELLNESS PHARMACY OF ST AUGUSTINE LLC
Other - Org Name:WELLNESS PHARMACY OF ST AUGUSTINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DINO
Authorized Official - Middle Name:
Authorized Official - Last Name:AJLONI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:904-429-7333
Mailing Address - Street 1:4405 SARTILLO RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-5240
Mailing Address - Country:US
Mailing Address - Phone:904-429-7333
Mailing Address - Fax:904-460-2695
Practice Address - Street 1:4405 SARTILLO RD
Practice Address - Street 2:SUITE B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-5240
Practice Address - Country:US
Practice Address - Phone:904-429-7333
Practice Address - Fax:904-460-2695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH269183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009136100Medicaid
5715252OtherNABP
FLPH26918OtherFLORIDA BOARD OF PHARMACY LICENSE NUMBER