Provider Demographics
NPI:1336416171
Name:WELLS SPECIALTY PHARMACY
Entity Type:Organization
Organization Name:WELLS SPECIALTY PHARMACY
Other - Org Name:PHARM-EZ MEDICAL LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMLINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-383-2004
Mailing Address - Street 1:803 SOUTH ORLANDO AVENUE
Mailing Address - Street 2:SUITE D
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789
Mailing Address - Country:US
Mailing Address - Phone:407-965-3980
Mailing Address - Fax:407-965-2978
Practice Address - Street 1:803 SOUTH ORLANDO AVENUE
Practice Address - Street 2:SUITE D
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789
Practice Address - Country:US
Practice Address - Phone:407-965-3980
Practice Address - Fax:407-965-2978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
FLPH257803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132816OtherPK
FL004633400Medicaid