MEDICARE: AUSTIN WELLNESS PHARMACY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	032977	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2176863	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376040683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN WELLNESS PHARMACY, LLC

Provider Business Mailing Address
First Line	:	6902 AUSTIN ST
Second Line	:	SUITE G3
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-4233
Country	:	US
Telephone Number	:	718-263-6688
Fax Number	:	718-263-6690

Provider Business Practice Location Address
First Line	:	6902 AUSTIN ST STE G3
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-4250
Country	:	US
Telephone Number	:	718-263-6688
Fax Number	:	718-263-6690

Authorized Official
Title or Position	:	OWNER
Name	:	STEVE CADDICK
Credential	:
Telephone Number	:	570-877-2536

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	04/12/2018

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