Provider Demographics
NPI:1104920156
Name:HEALTHWISE PHARMACY
Entity type:Organization
Organization Name:HEALTHWISE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:VIRAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:813-932-6337
Mailing Address - Street 1:2708 W WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-1837
Mailing Address - Country:US
Mailing Address - Phone:813-932-6337
Mailing Address - Fax:813-932-7455
Practice Address - Street 1:2708 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-1837
Practice Address - Country:US
Practice Address - Phone:813-932-6337
Practice Address - Fax:813-932-7455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH131813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102894400Medicaid
2013524OtherPK