Provider Demographics
NPI:1790013076
Name:WAUSAUKEE PHARMACY INC
Entity Type:Organization
Organization Name:WAUSAUKEE PHARMACY INC
Other - Org Name:WAUSAUKEE HEALTHMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-856-5455
Mailing Address - Street 1:703 MAIN ST
Mailing Address - Street 2:PO BOX 346
Mailing Address - City:WAUSAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:54177
Mailing Address - Country:US
Mailing Address - Phone:715-856-5455
Mailing Address - Fax:715-856-5451
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:STE 2
Practice Address - City:WAUSAUKEE
Practice Address - State:WI
Practice Address - Zip Code:54177
Practice Address - Country:US
Practice Address - Phone:715-856-5455
Practice Address - Fax:715-856-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8961-0423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy