Provider Demographics
NPI:1558345223
Name:FREEMAN DRUG, INC
Entity Type:Organization
Organization Name:FREEMAN DRUG, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-425-2255
Mailing Address - Street 1:104 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-2423
Mailing Address - Country:US
Mailing Address - Phone:715-425-2255
Mailing Address - Fax:715-425-2889
Practice Address - Street 1:104 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-2423
Practice Address - Country:US
Practice Address - Phone:715-425-2255
Practice Address - Fax:715-425-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WI4273333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33078400Medicaid
0165210001Medicare NSC