MEDICARE: ALLWELL PHARMACY AND MEDICAL SUPPLIES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336L0003X	Long Term Care Pharmacy
3	3336C0003X	Community/Retail Pharmacy	50426	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2127540	OTHER		PK

General Provider Information

NPI Number	:	1225339021
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLWELL PHARMACY AND MEDICAL SUPPLIES LLC

Provider Business Mailing Address
First Line	:	5611 STOCKTON BLVD
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95824-1611
Country	:	US
Telephone Number	:	916-457-2905
Fax Number	:	916-457-2140

Provider Business Practice Location Address
First Line	:	5611 STOCKTON BLVD
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95824-1611
Country	:	US
Telephone Number	:	916-457-2905
Fax Number	:	916-457-2140

Authorized Official
Title or Position	:	OWNER/PHARMACIST
Name	:	CLETUS DURU
Credential	:	PHARM.D
Telephone Number	:	916-690-3585

Provider Enumeration Date	:	11/10/2010
Last Update Date	:	07/02/2014

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