Provider Demographics
NPI:1346285707
Name:VOSMEK DRUG STORE INC
Entity Type:Organization
Organization Name:VOSMEK DRUG STORE INC
Other - Org Name:LAKESIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FREY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-623-2631
Mailing Address - Street 1:536 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2221
Mailing Address - Country:US
Mailing Address - Phone:715-623-2631
Mailing Address - Fax:715-623-6887
Practice Address - Street 1:536 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2221
Practice Address - Country:US
Practice Address - Phone:715-623-2631
Practice Address - Fax:715-623-6887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI78130423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33082400Medicaid
WI33082400Medicaid