Provider Demographics
NPI:1659770113
Name:IN THE WOODS APOTHECARY
Entity Type:Organization
Organization Name:IN THE WOODS APOTHECARY
Other - Org Name:SIREN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-349-2221
Mailing Address - Street 1:PO BOX 503
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-0503
Mailing Address - Country:US
Mailing Address - Phone:715-349-2221
Mailing Address - Fax:715-349-7350
Practice Address - Street 1:24106 STATE RD 35
Practice Address - Street 2:
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872
Practice Address - Country:US
Practice Address - Phone:715-349-2221
Practice Address - Fax:855-848-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336I0012X
WI9275-423336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659770113Medicaid
2147456OtherPK