Provider Demographics
NPI:1790890747
Name:CHIPPEWA PHARMACY INC
Entity Type:Organization
Organization Name:CHIPPEWA PHARMACY INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WINGER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-723-9192
Mailing Address - Street 1:603 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-2424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:603 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2424
Practice Address - Country:US
Practice Address - Phone:715-723-9192
Practice Address - Fax:715-723-6463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI87213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5120922OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI33296800Medicaid
WI33296800Medicaid
WIFT0139469OtherDEA #