Provider Demographics
NPI:1659317147
Name:WELLS PHARMACY, INC
Entity Type:Organization
Organization Name:WELLS PHARMACY, INC
Other - Org Name:WELLS PHARMACY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YI YI
Authorized Official - Middle Name:
Authorized Official - Last Name:SUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-949-6889
Mailing Address - Street 1:PO BOX 1207
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91785-1207
Mailing Address - Country:US
Mailing Address - Phone:909-949-6889
Mailing Address - Fax:909-949-2188
Practice Address - Street 1:1984 INDIAN HILL BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3620
Practice Address - Country:US
Practice Address - Phone:909-949-6889
Practice Address - Fax:909-949-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY544503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2114101OtherPK
CAPHA54450Medicaid
CAPHA54450Medicaid