Provider Demographics
NPI:1790793446
Name:WHITEFISH BAY PRESCRIPTION CENTER LTD
Entity Type:Organization
Organization Name:WHITEFISH BAY PRESCRIPTION CENTER LTD
Other - Org Name:YE OLDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:WACLAWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:414-963-0811
Mailing Address - Street 1:5320 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-963-0811
Mailing Address - Fax:414-963-0830
Practice Address - Street 1:5320 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-963-0811
Practice Address - Fax:414-963-0830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8527183500000X
WI72963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33002200Medicaid
WI33002200Medicaid