Provider Demographics
NPI:1679843700
Name:GRASS ROOTS HEALTH FOODS
Entity Type:Organization
Organization Name:GRASS ROOTS HEALTH FOODS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-479-6299
Mailing Address - Street 1:3440 STATE HIGHWAY 70 E
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-9491
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3440 STATE HIGHWAY 70 E
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-9491
Practice Address - Country:US
Practice Address - Phone:715-479-6299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI335G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335G00000XSuppliersMedical Foods Supplier