=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225574742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS PLUS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2017
-----------------------------------------------------
Last Update Date | 07/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1076 SPRINGFIELD AVE UNIT 1
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-2467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-399-1150
-----------------------------------------------------
Fax | 973-399-1143
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1076 SPRINGFIELD AVE UNIT 1
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-2467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-399-1150
-----------------------------------------------------
Fax | 973-399-1143
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | MR. OLUSEGUN BOLA ADEYEMO
-----------------------------------------------------
Credential | BSC.
-----------------------------------------------------
Telephone | 201-674-9612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 28RS00753800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------