Provider Demographics
NPI:1740363274
Name:WELLDYNERX, LLC
Entity type:Organization
Organization Name:WELLDYNERX, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LEGAL, REGULATORY AND COMPLIANCE AD
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LOVERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-479-2000
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:888-479-2000
Mailing Address - Fax:863-686-5682
Practice Address - Street 1:7472 S TUCSON WAY
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-4452
Practice Address - Country:US
Practice Address - Phone:888-479-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO370000050333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0614708OtherNCPDP
CO02459329Medicaid
6194380001Medicare NSC