Provider Demographics
NPI:1093447484
Name:WELLMAN, BEVERLY NICOLE
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:NICOLE
Last Name:WELLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 ALPINE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-3859
Mailing Address - Country:US
Mailing Address - Phone:619-659-1085
Mailing Address - Fax:619-659-5738
Practice Address - Street 1:1665 ALPINE BLVD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3859
Practice Address - Country:US
Practice Address - Phone:619-659-1085
Practice Address - Fax:619-659-5738
Is Sole Proprietor?:No
Enumeration Date:2022-06-25
Last Update Date:2022-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATCH94131183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician