Provider Demographics
NPI:1750717849
Name:WELLNESS PHARMACY SERVICES LLC
Entity type:Organization
Organization Name:WELLNESS PHARMACY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAYLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-277-7132
Mailing Address - Street 1:108 GUINNESS LN
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1234
Mailing Address - Country:US
Mailing Address - Phone:215-277-7132
Mailing Address - Fax:215-277-7135
Practice Address - Street 1:1427 HORSHAM ROAD
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-0312
Practice Address - Country:US
Practice Address - Phone:215-277-7132
Practice Address - Fax:215-277-7135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
PAPP482424333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102863688-0001Medicaid
2142205OtherPK
PA102863688-0001Medicaid