Healthcare Provider Details

I. General information

NPI: 1861187833
Provider Name (Legal Business Name): BEWELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5346 MADISON AVE STE A
SACRAMENTO CA
95841-3168
US

IV. Provider business mailing address

5346 MADISON AVE STE A
SACRAMENTO CA
95841-3168
US

V. Phone/Fax

Practice location:
  • Phone: 916-800-6004
  • Fax: 916-249-1449
Mailing address:
  • Phone: 916-800-6004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. DEMITRI DUKHOVNY
Title or Position: MANAGING MEMBER/CEO
Credential:
Phone: 858-218-3330