Provider Demographics
NPI:1639174980
Name:BELLICOSE INTERNATIONAL INC.
Entity Type:Organization
Organization Name:BELLICOSE INTERNATIONAL INC.
Other - Org Name:WOOD RIVER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP RDO
Authorized Official - Prefix:
Authorized Official - First Name:SELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:DZELIL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:815-715-8502
Mailing Address - Street 1:122 W MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-7022
Mailing Address - Country:US
Mailing Address - Phone:715-463-2525
Mailing Address - Fax:715-463-5343
Practice Address - Street 1:122 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7022
Practice Address - Country:US
Practice Address - Phone:715-463-2525
Practice Address - Fax:715-463-5343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6872332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000086607OtherMEDICARE
WI5106047OtherNABP
WI33154200Medicaid
WI0178900001Medicare NSC