Provider Demographics
NPI:1114353018
Name:WELLS PHARMACY LLC
Entity type:Organization
Organization Name:WELLS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-298-2080
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:INEZ
Mailing Address - State:KY
Mailing Address - Zip Code:41224-0395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 BOARDWALK ST STE 2
Practice Address - Street 2:
Practice Address - City:INEZ
Practice Address - State:KY
Practice Address - Zip Code:41224-7003
Practice Address - Country:US
Practice Address - Phone:606-298-2080
Practice Address - Fax:606-298-2081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP075963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142214OtherPK
2142214OtherPK