Provider Demographics
NPI:1073606406
Name:VILLAGE BAKE SHOP INC
Entity Type:Organization
Organization Name:VILLAGE BAKE SHOP INC
Other - Org Name:QUILLINS MAJOR DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEAD PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-784-6200
Mailing Address - Street 1:3954 MORMON COULEE RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7916
Mailing Address - Country:US
Mailing Address - Phone:608-784-6200
Mailing Address - Fax:608-784-3808
Practice Address - Street 1:3954 MORMON COULEE RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7916
Practice Address - Country:US
Practice Address - Phone:608-784-6200
Practice Address - Fax:608-784-3808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WI7708-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33060500Medicaid
5104687OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN636560400Medicaid
WI33060500Medicaid