Provider Demographics
NPI:1043269020
Name:WAUPACA WOODS PHARMACY, INC.
Entity Type:Organization
Organization Name:WAUPACA WOODS PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-258-7621
Mailing Address - Street 1:101 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-2201
Mailing Address - Country:US
Mailing Address - Phone:715-258-7621
Mailing Address - Fax:715-258-6880
Practice Address - Street 1:101 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-2201
Practice Address - Country:US
Practice Address - Phone:715-258-7621
Practice Address - Fax:715-258-6880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33035600Medicaid
WI5116264OtherNABP
WI5116264OtherNABP
WI0200490001Medicare ID - Type Unspecified