Provider Demographics
NPI:1548307648
Name:WELAKA PHARMACY LLC
Entity type:Organization
Organization Name:WELAKA PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:386-467-9994
Mailing Address - Street 1:698 THIRD AVE
Mailing Address - Street 2:
Mailing Address - City:WELAKA
Mailing Address - State:FL
Mailing Address - Zip Code:32193
Mailing Address - Country:US
Mailing Address - Phone:386-467-9994
Mailing Address - Fax:386-467-3112
Practice Address - Street 1:698 THIRD AVENUE
Practice Address - Street 2:
Practice Address - City:WELAKA
Practice Address - State:FL
Practice Address - Zip Code:32193
Practice Address - Country:US
Practice Address - Phone:386-467-9994
Practice Address - Fax:386-467-3112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH16228332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106512201Medicaid
FLP7787OtherBCBS
FLP7787OtherBCBS