Provider Demographics
NPI:1265083729
Name:WELLDYNERX, LLC
Entity type:Organization
Organization Name:WELLDYNERX, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLEISCHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:863-583-6063
Mailing Address - Street 1:500 EAGLES LANDING DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-2899
Mailing Address - Country:US
Mailing Address - Phone:863-583-6523
Mailing Address - Fax:
Practice Address - Street 1:500 EAGLES LANDING DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-2899
Practice Address - Country:US
Practice Address - Phone:863-583-6523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-26
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024462370001Medicaid
WA1093974982Medicaid
OK20029370AMedicaid
IN200972230AMedicaid
WI100080584Medicaid
KS200636740AMedicaid
CO9000170493Medicaid
MD03285290Medicaid
MI20200323899433Medicaid
VT1017697Medicaid
FL001055000Medicaid
IA0205365Medicaid
MN1093974982Medicaid
ID1093974982Medicaid