Provider Demographics
NPI:1184068272
Name:WELLS, MARIETTA (RPH)
Entity type:Individual
Prefix:
First Name:MARIETTA
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4503 JFK PARKWAY
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525
Mailing Address - Country:US
Mailing Address - Phone:970-223-5769
Mailing Address - Fax:970-223-5844
Practice Address - Street 1:1275 EAGLE DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-8058
Practice Address - Country:US
Practice Address - Phone:970-663-2048
Practice Address - Fax:970-223-5844
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03003936Medicaid