=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164932273
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLWELL PHARMACY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2017
-----------------------------------------------------
Last Update Date | 10/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1235 INDIAN TRAIL LILBURN RD STE B401 SUITE- B 401
-----------------------------------------------------
City | NORCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30093-5524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-331-7964
-----------------------------------------------------
Fax | 770-864-5645
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4430 EGRET AVE
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30041-4769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-331-7964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | AMIT PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-331-7964
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE010387
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------