=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962703025
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JL WELLNESS PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2010
-----------------------------------------------------
Last Update Date | 03/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3030 TOWNE CENTRE DR STE B
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-4134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-364-1793
-----------------------------------------------------
Fax | 972-364-1916
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3030 TOWNE CENTRE DR STE B
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-4134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-364-1793
-----------------------------------------------------
Fax | 972-364-1916
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | MR. BRIAN PICCHI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-364-1793
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | S1545
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number | 1000726
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | S1545
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 27232
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------