Provider Demographics
NPI:1780796615
Name:WELLS SPECIALTY PHARMACY INC
Entity type:Organization
Organization Name:WELLS SPECIALTY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP CLINICAL OPERATIONS AND SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:HEGLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-331-1449
Mailing Address - Street 1:3796 HOWELL BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-1740
Mailing Address - Country:US
Mailing Address - Phone:407-671-8070
Mailing Address - Fax:
Practice Address - Street 1:3796 HOWELL BRANCH RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-1740
Practice Address - Country:US
Practice Address - Phone:407-915-3360
Practice Address - Fax:407-386-3082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336H0001X, 3336M0002X, 3336C0003X
FLPH132983336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1074993OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL102946100Medicaid
FLBM4362834OtherDEA #
FL102946100Medicaid