Provider Demographics
NPI:1053917583
Name:WELL MART & PHARMACY LLC
Entity type:Organization
Organization Name:WELL MART & PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEONG
Authorized Official - Middle Name:IN
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-482-4705
Mailing Address - Street 1:2182 LEMOINE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6009
Mailing Address - Country:US
Mailing Address - Phone:201-482-4705
Mailing Address - Fax:201-482-4905
Practice Address - Street 1:2182 LEMOINE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6009
Practice Address - Country:US
Practice Address - Phone:201-482-4705
Practice Address - Fax:201-482-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RS00781700OtherNJ PHARMACY LICENSE NUMBER