Provider Demographics
NPI:1710099718
Name:WHEATON DRUG COMAPNY
Entity Type:Organization
Organization Name:WHEATON DRUG COMAPNY
Other - Org Name:WHEATON DRUG COMAPNY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NERENZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:320-563-4151
Mailing Address - Street 1:1105 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MN
Mailing Address - Zip Code:56296-1307
Mailing Address - Country:US
Mailing Address - Phone:320-563-4151
Mailing Address - Fax:320-563-4577
Practice Address - Street 1:1105 BROADWAY
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MN
Practice Address - Zip Code:56296-1307
Practice Address - Country:US
Practice Address - Phone:320-563-4151
Practice Address - Fax:320-563-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2612323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045781OtherPK
MN215257600Medicaid
SD8530410Medicaid
1145790001Medicare NSC