=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780126771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLCARE HEALTHCARE PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2016
-----------------------------------------------------
Last Update Date | 09/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9493 GARFIELD ST
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92503-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-299-7100
-----------------------------------------------------
Fax | 951-299-7959
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9493 GARFIELD ST
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92503-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-299-7100
-----------------------------------------------------
Fax | 951-299-7959
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BADAL SATASIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-299-7100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 54630
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------