Provider Demographics
NPI:1750673919
Name:RESTORE HEALTH PHARMACY, LLC
Entity Type:Organization
Organization Name:RESTORE HEALTH PHARMACY, LLC
Other - Org Name:RESTORE HEALTH PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WANDERER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:480-421-8005
Mailing Address - Street 1:1289 DEMING WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2007
Mailing Address - Country:US
Mailing Address - Phone:800-558-7046
Mailing Address - Fax:888-898-7412
Practice Address - Street 1:1289 DEMING WAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2007
Practice Address - Country:US
Practice Address - Phone:800-558-7046
Practice Address - Fax:888-898-7412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9070-0423336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130190OtherPK