Provider Demographics
NPI:1972739415
Name:WELLNESS CENTER PHARMACY INC
Entity Type:Organization
Organization Name:WELLNESS CENTER PHARMACY INC
Other - Org Name:WELLNESS CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARWA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALIFA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-956-0060
Mailing Address - Street 1:4013 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4082
Mailing Address - Country:US
Mailing Address - Phone:718-956-0060
Mailing Address - Fax:718-956-0065
Practice Address - Street 1:4013 BROADWAY
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4082
Practice Address - Country:US
Practice Address - Phone:718-956-0060
Practice Address - Fax:718-956-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0294833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03124132Medicaid
2120556OtherPK