Provider Demographics
NPI:1518394857
Name:MISSION WELLNESS HEALTHCARE LLC
Entity Type:Organization
Organization Name:MISSION WELLNESS HEALTHCARE LLC
Other - Org Name:MISSION WELLNESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRZEJEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-826-3484
Mailing Address - Street 1:PO BOX 7775 #52191
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94120
Mailing Address - Country:US
Mailing Address - Phone:415-826-3484
Mailing Address - Fax:415-738-7947
Practice Address - Street 1:2424 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2415
Practice Address - Country:US
Practice Address - Phone:415-826-3484
Practice Address - Fax:415-826-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
CA543903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142357OtherPK
CAPHA471220Medicaid