Provider Demographics
NPI:1184215105
Name:INDIANA WELLNESS RX LLC
Entity Type:Organization
Organization Name:INDIANA WELLNESS RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRILL
Authorized Official - Middle Name:
Authorized Official - Last Name:VESSELOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:930-888-3990
Mailing Address - Street 1:215 W 4TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-1917
Mailing Address - Country:US
Mailing Address - Phone:574-544-0102
Mailing Address - Fax:
Practice Address - Street 1:215 W 4TH ST STE 1
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1917
Practice Address - Country:US
Practice Address - Phone:574-544-0102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy