Healthcare Provider Details

I. General information

NPI: 1902252521
Provider Name (Legal Business Name): WELLNESS PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4640 CHAMPLAIN DR 113
LINCOLN NE
68521-4714
US

IV. Provider business mailing address

4640 CHAMPLAIN DR STE 113
LINCOLN NE
68521-4714
US

V. Phone/Fax

Practice location:
  • Phone: 402-413-9950
  • Fax: 402-413-9964
Mailing address:
  • Phone: 402-413-9950
  • Fax: 402-413-9964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number3100
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KAYLA A PHAM
Title or Position: PRESIDENT/CEO
Credential:
Phone: 402-304-7564