Provider Demographics
NPI:1639248172
Name:WAUPACA WOODS PHARMACY INC.
Entity Type:Organization
Organization Name:WAUPACA WOODS PHARMACY INC.
Other - Org Name:RIVERSIDE CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:OESTREICH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-256-1115
Mailing Address - Street 1:101 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-2201
Mailing Address - Country:US
Mailing Address - Phone:715-258-7621
Mailing Address - Fax:715-258-6880
Practice Address - Street 1:800 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1943
Practice Address - Country:US
Practice Address - Phone:715-256-1115
Practice Address - Fax:715-256-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77393336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33228100Medicaid
WI0200490001Medicare ID - Type Unspecified