Provider Demographics
NPI:1093216285
Name:MARINETTE-MENOMINEE PRESCRIPTION CENTER LTD
Entity Type:Organization
Organization Name:MARINETTE-MENOMINEE PRESCRIPTION CENTER LTD
Other - Org Name:VALUCARE LONG TERM CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKE
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:715-732-0717
Mailing Address - Street 1:1378 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-2425
Mailing Address - Country:US
Mailing Address - Phone:715-732-0717
Mailing Address - Fax:715-732-0596
Practice Address - Street 1:1378 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-2425
Practice Address - Country:US
Practice Address - Phone:715-732-0717
Practice Address - Fax:715-732-0596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
WI9392-423336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176150OtherPK
WI33114900Medicaid