Provider Demographics
NPI:1790034460
Name:WELLS PHARMACY NETWORK LLC
Entity Type:Organization
Organization Name:WELLS PHARMACY NETWORK LLC
Other - Org Name:WELLS PHARMACY NETWORK LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-882-7000
Mailing Address - Street 1:450 US HIGHWAY 51 BYP N
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3655
Mailing Address - Country:US
Mailing Address - Phone:731-882-7000
Mailing Address - Fax:731-882-7000
Practice Address - Street 1:450 US HIGHWAY 51 BYP N
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3655
Practice Address - Country:US
Practice Address - Phone:731-882-7000
Practice Address - Fax:731-882-7000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN50583336C0003X
3336C0004X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4445272OtherNCPDP PROVIDER IDENTIFICATION NUMBER