Provider Demographics
NPI:1952819591
Name:WELLNESS WARE INC
Entity Type:Organization
Organization Name:WELLNESS WARE INC
Other - Org Name:PEGGY L. MEDINA DBA WELLNESS WARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-956-7647
Mailing Address - Street 1:1547 NE F ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-4234
Mailing Address - Country:US
Mailing Address - Phone:541-956-7647
Mailing Address - Fax:541-956-8739
Practice Address - Street 1:1547 NE F ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-4234
Practice Address - Country:US
Practice Address - Phone:541-956-7647
Practice Address - Fax:541-956-8739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR247509Medicaid
OR820461000OtherREGENCE BCBS OREGON
ORJE-400-01OtherPACIFIC SOURCE