Provider Demographics
NPI:1295106987
Name:WELL CARE PHARMACY I, LLC SERIES A
Entity type:Organization
Organization Name:WELL CARE PHARMACY I, LLC SERIES A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEUOKAGHAEI
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:702-410-7825
Mailing Address - Street 1:3312 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1829
Mailing Address - Country:US
Mailing Address - Phone:702-410-7825
Mailing Address - Fax:702-946-0409
Practice Address - Street 1:5446 BOULDER HWY STE G3
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-6069
Practice Address - Country:US
Practice Address - Phone:702-291-7121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty