Provider Demographics
NPI:1457602294
Name:MARIN WELLNESS PHARMACY LLC
Entity type:Organization
Organization Name:MARIN WELLNESS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOUSSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAILEMARIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-953-4528
Mailing Address - Street 1:3299 E HILL ST
Mailing Address - Street 2:STE 301
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-1231
Mailing Address - Country:US
Mailing Address - Phone:562-597-6800
Mailing Address - Fax:562-597-6844
Practice Address - Street 1:3299 E HILL ST
Practice Address - Street 2:STE 301
Practice Address - City:SIGNAL HILL
Practice Address - State:CA
Practice Address - Zip Code:90755-1231
Practice Address - Country:US
Practice Address - Phone:562-597-6800
Practice Address - Fax:562-597-6844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1457602294Medicaid
2137050OtherPK