Healthcare Provider Details

I. General information

NPI: 1295249860
Provider Name (Legal Business Name): CARSON WELLNESS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2017
Last Update Date: 11/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22005 AVALON BLVD STE D
CARSON CA
90745-7169
US

IV. Provider business mailing address

20111 WADLEY AVE
CARSON CA
90746-3046
US

V. Phone/Fax

Practice location:
  • Phone: 424-295-7979
  • Fax: 424-295-7999
Mailing address:
  • Phone: 310-422-6586
  • Fax: 424-295-7999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number55785
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number55785
License Number StateCA

VIII. Authorized Official

Name: DR. CHIDINMA JENNY CHIKEZIE
Title or Position: PHARMACIST
Credential: PHARMD
Phone: 310-422-6586