Provider Demographics
NPI:1902252521
Name:WELLNESS PHARMACY, INC
Entity Type:Organization
Organization Name:WELLNESS PHARMACY, INC
Other - Org Name:SPECIALTY COMPOUNDING PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-304-7564
Mailing Address - Street 1:4640 CHAMPLAIN DR
Mailing Address - Street 2:113
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-4714
Mailing Address - Country:US
Mailing Address - Phone:402-413-9950
Mailing Address - Fax:402-413-9964
Practice Address - Street 1:4640 CHAMPLAIN DR
Practice Address - Street 2:113
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-4714
Practice Address - Country:US
Practice Address - Phone:402-413-9950
Practice Address - Fax:402-413-9964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE31003336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026581700Medicaid