=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134637044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS PLUS PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2018
-----------------------------------------------------
Last Update Date | 08/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 FLUSHING AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-443-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 FLUSHING AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11206-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-443-3900
-----------------------------------------------------
Fax | 718-443-3901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. LAMIS MOHAMAD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-820-0059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 036030
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------