MEDICARE: WIG DOCTOR RX INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224P00000X	Prosthetist

General Provider Information

NPI Number	:	1386456267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIG DOCTOR RX INC.

Provider Business Mailing Address
First Line	:	2600 ART MUSEUM DR APT 176
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-4849
Country	:	US
Telephone Number	:	904-430-2420
Fax Number	:

Provider Business Practice Location Address
First Line	:	1839 LANE AVE S STE 101
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-1260
Country	:	US
Telephone Number	:	904-775-3071
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RANDE HARRIS
Credential	:
Telephone Number	:	904-430-2420

Provider Enumeration Date	:	01/27/2025
Last Update Date	:	01/27/2025

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Directions to “WIG DOCTOR RX INC. ” Practice Location

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