Provider Demographics
NPI:1457648297
Name:WELLS, ROBERT III (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WELLS
Suffix:III
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16925 UNIVERSITY CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-3146
Mailing Address - Country:US
Mailing Address - Phone:708-331-9696
Mailing Address - Fax:708-333-1224
Practice Address - Street 1:1717 E WEST RD # T-0846
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5414
Practice Address - Country:US
Practice Address - Phone:708-730-3101
Practice Address - Fax:708-730-3101
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-032945183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist