Provider Demographics
NPI:1073528667
Name:WANZEK PHARMACY INC
Entity Type:Organization
Organization Name:WANZEK PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WANZEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-642-3218
Mailing Address - Street 1:12 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADELIA
Mailing Address - State:MN
Mailing Address - Zip Code:56062-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MADELIA
Practice Address - State:MN
Practice Address - Zip Code:56062-1438
Practice Address - Country:US
Practice Address - Phone:507-642-3218
Practice Address - Fax:507-642-8651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2606635333600000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN182557700Medicaid
2402941OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2402941OtherOTHER ID NUMBER-COMMERCIAL NUMBER