Provider Demographics
NPI:1356619456
Name:WELLNESS RX AT PENALVER LLC
Entity type:Organization
Organization Name:WELLNESS RX AT PENALVER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-545-4860
Mailing Address - Street 1:971 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33128-1205
Mailing Address - Country:US
Mailing Address - Phone:305-545-4860
Mailing Address - Fax:305-545-4867
Practice Address - Street 1:971 NW 2ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33128-1205
Practice Address - Country:US
Practice Address - Phone:305-545-4860
Practice Address - Fax:305-545-4867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH 258053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5708346OtherNCPDP PROVIDER IDENTIFICATION NUMBER