Healthcare Provider Details

I. General information

NPI: 1609108356
Provider Name (Legal Business Name): MEDWELLRX II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 02/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NORTHGATE PKWY STE C
WHEELING IL
60090-3201
US

IV. Provider business mailing address

11134 Q ST
OMAHA NE
68137-3609
US

V. Phone/Fax

Practice location:
  • Phone: 847-459-7011
  • Fax: 847-459-7036
Mailing address:
  • Phone: 402-592-5244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number320.009686
License Number StateIL

VIII. Authorized Official

Name: TIMOTHY DECKER
Title or Position: CEO
Credential:
Phone: 402-763-6560