Provider Demographics
NPI:1992711782
Name:PETCO WELLNESS LLC
Entity type:Organization
Organization Name:PETCO WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARRAGH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-657-2091
Mailing Address - Street 1:10850 VIA FRONTERA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1705
Mailing Address - Country:US
Mailing Address - Phone:858-453-7845
Mailing Address - Fax:858-638-2201
Practice Address - Street 1:2253 AIR PARK RD
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-8425
Practice Address - Country:US
Practice Address - Phone:800-447-3021
Practice Address - Fax:800-447-2404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9291-423336M0002X
3336L0003X, 333600000X
WI82660423336M0002X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150646OtherPK