MEDICARE: WELLNESS COMPOUNDING PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy
3	3336C0004X	Compounding Pharmacy	RP002452C0S	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2079579	OTHER		PK

General Provider Information

NPI Number	:	1063682805
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS COMPOUNDING PHARMACY

Provider Business Mailing Address
First Line	:	522 CRATER LAKE AVENUE
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504
Country	:	US
Telephone Number	:	541-774-3939
Fax Number	:	541-774-3933

Provider Business Practice Location Address
First Line	:	522 CRATER LAKE AVE
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-6810
Country	:	US
Telephone Number	:	541-774-3939
Fax Number	:	541-774-3933

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANGIE MEEKER
Credential	:	PHARMD
Telephone Number	:	541-301-1465

Provider Enumeration Date	:	03/07/2008
Last Update Date	:	09/19/2025

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Directions to “WELLNESS COMPOUNDING PHARMACY ” Practice Location

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