Provider Demographics
NPI:1033120688
Name:PAPER VALLEY PHARMACY INC
Entity Type:Organization
Organization Name:PAPER VALLEY PHARMACY INC
Other - Org Name:FORD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-738-4105
Mailing Address - Street 1:1440 ONEIDA ST
Mailing Address - Street 2:STE A
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1440 ONEIDA ST
Practice Address - Street 2:STE A
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-7101
Practice Address - Country:US
Practice Address - Phone:920-738-4105
Practice Address - Fax:920-738-4100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8575042333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5121188OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI33187200Medicaid
WI33187200Medicaid