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General NPI Number Information
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NPI Number | 1972984722
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Entity Type | Organization
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Legal Business Name | MARIN WELLNESS PHARMACY, INC.
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Dates
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Enumeration Date | 06/17/2015
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Last Update Date | 11/19/2024
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Provider Practice Location Address
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Address Line | 55 MITCHELL BLVD STE 11
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City | SAN RAFAEL
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State | CA
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Zip | 94903-2010
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Country | US
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Telephone | 415-521-1555
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Fax | 415-299-8619
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Provider Business Mailing Address
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Address Line | 55 MITCHELL BLVD SUITE 11
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City | SAN RAFAEL
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State | CA
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Zip | 94903-2082
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Country | US
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Telephone | 415-521-1555
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Fax | 415-299-8619
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Authorized Official
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Title or Position | PRESIDENT
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Name | MOUSSIE HAILEMARIAM
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Credential |
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Telephone | 707-953-4528
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 53342
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License Number State | CA
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