Provider Demographics
NPI:1144384629
Name:FALL CREEK PHARMACY, INC.
Entity Type:Organization
Organization Name:FALL CREEK PHARMACY, INC.
Other - Org Name:FALL CREEK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH /STORE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:J
Authorized Official - Last Name:STONER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-877-2994
Mailing Address - Street 1:119 E LINCOLN AVE
Mailing Address - Street 2:PO BOX 217
Mailing Address - City:FALL CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54742-9526
Mailing Address - Country:US
Mailing Address - Phone:715-877-2994
Mailing Address - Fax:715-877-3248
Practice Address - Street 1:119 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FALL CREEK
Practice Address - State:WI
Practice Address - Zip Code:54742-9526
Practice Address - Country:US
Practice Address - Phone:715-877-2994
Practice Address - Fax:715-877-3248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI89030423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1144384629Medicaid
WI1144384629Medicaid