Provider Demographics
NPI:1124358940
Name:BADGER PHARMACY LLC
Entity Type:Organization
Organization Name:BADGER PHARMACY LLC
Other - Org Name:YOUNG'S DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-842-0370
Mailing Address - Street 1:555 S 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-9038
Mailing Address - Country:US
Mailing Address - Phone:715-842-0370
Mailing Address - Fax:715-842-0366
Practice Address - Street 1:2106 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6912
Practice Address - Country:US
Practice Address - Phone:715-845-3713
Practice Address - Fax:715-845-7957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8993-0423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1124358940Medicaid
5132131OtherNCPDP
6485670002Medicare NSC