Provider Demographics
NPI:1912373358
Name:HAYWOOD RX, LLC DBA OPTIMUM WELLNESS PHARMACY
Entity Type:Organization
Organization Name:HAYWOOD RX, LLC DBA OPTIMUM WELLNESS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:812-457-1204
Mailing Address - Street 1:8900 RUFFIAN LN
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-3424
Mailing Address - Country:US
Mailing Address - Phone:812-457-1204
Mailing Address - Fax:
Practice Address - Street 1:8900 RUFFIAN LN
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-3424
Practice Address - Country:US
Practice Address - Phone:812-457-1204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN260205773336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy