Provider Demographics
NPI:1962703025
Name:JL WELLNESS PHARMACY, LLC
Entity type:Organization
Organization Name:JL WELLNESS PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PICCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-364-1793
Mailing Address - Street 1:3030 TOWNE CENTRE DR STE B
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4134
Mailing Address - Country:US
Mailing Address - Phone:972-364-1793
Mailing Address - Fax:972-364-1916
Practice Address - Street 1:3030 TOWNE CENTRE DR STE B
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4134
Practice Address - Country:US
Practice Address - Phone:972-364-1793
Practice Address - Fax:972-364-1916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS1545332B00000X, 335E00000X
TX1000726332BX2000X
TX272323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
5901649OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TX6698210001Medicare NSC