Healthcare Provider Details

I. General information

NPI: 1629871637
Provider Name (Legal Business Name): MARIN WELLNESS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 PROFESSIONAL CENTER DR STE C
ROHNERT PARK CA
94928-2169
US

IV. Provider business mailing address

3299 E HILL ST STE 301
SIGNAL HILL CA
90755-1231
US

V. Phone/Fax

Practice location:
  • Phone: 707-953-4528
  • Fax:
Mailing address:
  • Phone: 415-521-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MOUSSIE HAILEMARIAM
Title or Position: CEO
Credential:
Phone: 707-953-4528