Provider Demographics
NPI:1467454678
Name:BENZER WI 2 LLC
Entity Type:Organization
Organization Name:BENZER WI 2 LLC
Other - Org Name:PESHTIGO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BHARGAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-348-3003
Mailing Address - Street 1:220 FRENCH STREET
Mailing Address - Street 2:
Mailing Address - City:PESHTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54157
Mailing Address - Country:US
Mailing Address - Phone:813-304-2221
Mailing Address - Fax:888-239-8423
Practice Address - Street 1:220 FRENCH ST
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157-1218
Practice Address - Country:US
Practice Address - Phone:715-582-4237
Practice Address - Fax:715-582-0213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9304-423336C0003X
WI9491-423336C0003X
WI6122-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33094900Medicaid
2151000OtherPK