Provider Demographics
NPI:1710063128
Name:WELLS PHARMACY
Entity Type:Organization
Organization Name:WELLS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:EDMUND
Authorized Official - Last Name:BILLINGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:R PH
Authorized Official - Phone:719-767-5676
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE WELLS
Mailing Address - State:CO
Mailing Address - Zip Code:80810-0005
Mailing Address - Country:US
Mailing Address - Phone:719-767-5676
Mailing Address - Fax:719-767-5448
Practice Address - Street 1:180 SO. 1 E.
Practice Address - Street 2:
Practice Address - City:CHEYENNE WELLS
Practice Address - State:CO
Practice Address - Zip Code:80810-0005
Practice Address - Country:US
Practice Address - Phone:719-767-5676
Practice Address - Fax:719-767-5448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2300000023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03000429Medicaid