Provider Demographics
NPI:1124031463
Name:VILLAGE PHARMACY INC
Entity Type:Organization
Organization Name:VILLAGE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-897-5333
Mailing Address - Street 1:633 N HWY 141
Mailing Address - Street 2:BOX 186
Mailing Address - City:COLEMAN
Mailing Address - State:WI
Mailing Address - Zip Code:54112-0186
Mailing Address - Country:US
Mailing Address - Phone:920-897-5333
Mailing Address - Fax:920-897-5451
Practice Address - Street 1:633 N HWY 141
Practice Address - Street 2:BOX 186
Practice Address - City:COLEMAN
Practice Address - State:WI
Practice Address - Zip Code:54112-0186
Practice Address - Country:US
Practice Address - Phone:920-897-5333
Practice Address - Fax:920-897-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI84603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33257500Medicaid
WI5126582OtherNCPDP
WI4292220001Medicare ID - Type Unspecified