Provider Demographics
NPI:1811201742
Name:MEDFORD PHARMACY INC
Entity Type:Organization
Organization Name:MEDFORD PHARMACY INC
Other - Org Name:MEDFORD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:PROHASKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-415-1981
Mailing Address - Street 1:210 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1843
Mailing Address - Country:US
Mailing Address - Phone:715-748-4477
Mailing Address - Fax:715-748-5848
Practice Address - Street 1:210 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1843
Practice Address - Country:US
Practice Address - Phone:715-748-4477
Practice Address - Fax:715-748-5848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9018-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5132319OtherNCPDP PROVIDER IDENTIFICATION NUMBER