Provider Demographics
NPI:1356498406
Name:PSR WELLNESS LLC
Entity type:Organization
Organization Name:PSR WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PRATAP
Authorized Official - Middle Name:KRISHNA
Authorized Official - Last Name:ANNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-298-1715
Mailing Address - Street 1:1390 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-1124
Mailing Address - Country:US
Mailing Address - Phone:707-963-2794
Mailing Address - Fax:707-963-1954
Practice Address - Street 1:1390 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-1124
Practice Address - Country:US
Practice Address - Phone:707-963-2794
Practice Address - Fax:707-963-1954
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PSR WELLNESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-04
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY406333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356498406Medicaid
1993716OtherPK
CAPHA406330Medicaid