=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225511843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WETRIUM,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2018
-----------------------------------------------------
Last Update Date | 09/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 OHIO DR STE 115
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-298-0592
-----------------------------------------------------
Fax | 469-298-3404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 OHIO DR STE 115
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-298-0592
-----------------------------------------------------
Fax | 469-298-3404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | VARUN PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-298-0592
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------