Provider Demographics
NPI:1972984722
Name:MARIN WELLNESS PHARMACY, INC.
Entity type:Organization
Organization Name:MARIN WELLNESS PHARMACY, INC.
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 1:55 MITCHELL BLVD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2082
Mailing Address - Country:US
Mailing Address - Phone:415-521-1555
Mailing Address - Fax:415-299-8619
Practice Address - Street 1:55 MITCHELL BLVD STE 11
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2010
Practice Address - Country:US
Practice Address - Phone:415-521-1555
Practice Address - Fax:415-299-8619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
CA533423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152573OtherPK