Provider Demographics
NPI:1497298954
Name:DOZAK DRUG LLC
Entity Type:Organization
Organization Name:DOZAK DRUG LLC
Other - Org Name:WHEATON DRUG AND GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-563-4151
Mailing Address - Street 1:1105 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MN
Mailing Address - Zip Code:56296-1374
Mailing Address - Country:US
Mailing Address - Phone:320-563-4151
Mailing Address - Fax:320-563-4577
Practice Address - Street 1:1105 BROADWAY
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MN
Practice Address - Zip Code:56296-1307
Practice Address - Country:US
Practice Address - Phone:320-563-4151
Practice Address - Fax:320-563-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-30
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MN2652103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1497298954Medicaid
SD1497298954Medicaid
2166638OtherPK
2166638OtherPK