Provider Demographics
NPI:1023488681
Name:WELLMART RX, INC.
Entity type:Organization
Organization Name:WELLMART RX, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVYDOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-704-0808
Mailing Address - Street 1:21913 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-2126
Mailing Address - Country:US
Mailing Address - Phone:718-704-0808
Mailing Address - Fax:718-704-0818
Practice Address - Street 1:21913 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-2126
Practice Address - Country:US
Practice Address - Phone:718-704-0808
Practice Address - Fax:718-704-0818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7535470001Medicare NSC