Provider Demographics
NPI:1700946936
Name:PSR WELLNESS LLC
Entity type:Organization
Organization Name:PSR WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PRATAP
Authorized Official - Middle Name:K
Authorized Official - Last Name:ANNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-298-1715
Mailing Address - Street 1:1473 - D LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CALISTOGA
Mailing Address - State:CA
Mailing Address - Zip Code:94515-1479
Mailing Address - Country:US
Mailing Address - Phone:209-298-1715
Mailing Address - Fax:559-369-2408
Practice Address - Street 1:1473 - D LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1479
Practice Address - Country:US
Practice Address - Phone:707-942-5115
Practice Address - Fax:707-942-2175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY474753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700946936Medicaid
2033136OtherPK