Provider Demographics
NPI:1184405664
Name:WELLSTREET OF GEORGIA PC
Entity type:Organization
Organization Name:WELLSTREET OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-502-2121
Mailing Address - Street 1:716 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-1748
Mailing Address - Country:US
Mailing Address - Phone:330-426-8700
Mailing Address - Fax:330-426-8701
Practice Address - Street 1:716 N COURT ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1748
Practice Address - Country:US
Practice Address - Phone:330-426-8700
Practice Address - Fax:330-426-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site