Provider Demographics
NPI:1437264488
Name:MANITOWOC PHARMACIES INC
Entity Type:Organization
Organization Name:MANITOWOC PHARMACIES INC
Other - Org Name:HEALTH MART PULASKI PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:RESCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-253-2164
Mailing Address - Street 1:121 N SAINT AUGUSTINE ST
Mailing Address - Street 2:PO BOX 200
Mailing Address - City:PULASKI
Mailing Address - State:WI
Mailing Address - Zip Code:54162-7982
Mailing Address - Country:US
Mailing Address - Phone:920-822-3011
Mailing Address - Fax:920-822-3852
Practice Address - Street 1:121 N SAINT AUGUSTINE ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:WI
Practice Address - Zip Code:54162-7982
Practice Address - Country:US
Practice Address - Phone:920-822-3011
Practice Address - Fax:920-822-3852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI7901-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33240600Medicaid
2134085OtherPK
0318830005Medicare NSC