Healthcare Provider Details

I. General information

NPI: 1295286011
Provider Name (Legal Business Name): DYNAMIC WELLNES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12150 SW 128TH CT SUITE 217
MIAMI FL
33186-4647
US

IV. Provider business mailing address

12150 SW 128TH CT SUITE 217
MIAMI FL
33186-4647
US

V. Phone/Fax

Practice location:
  • Phone: 786-732-2595
  • Fax: 786-732-2595
Mailing address:
  • Phone: 786-732-2595
  • Fax: 786-732-2595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS37377
License Number StateFL

VIII. Authorized Official

Name: MRS. GISELE VELAZQUEZ
Title or Position: PHARMACIST
Credential: RPH, CPH
Phone: 305-815-0437