Provider Demographics
NPI:1477755601
Name:THE WELLNESS STORE, INC.
Entity Type:Organization
Organization Name:THE WELLNESS STORE, INC.
Other - Org Name:WELLSPRING CUSTOM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:ROSEBOROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:419-756-2559
Mailing Address - Street 1:2291 W 4TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-1261
Mailing Address - Country:US
Mailing Address - Phone:419-756-2559
Mailing Address - Fax:419-756-3135
Practice Address - Street 1:2291 W 4TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-1261
Practice Address - Country:US
Practice Address - Phone:419-756-2559
Practice Address - Fax:419-756-3135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy