Provider Demographics
NPI:1851390496
Name:ISLAND CITY APOTHECARY LTD
Entity Type:Organization
Organization Name:ISLAND CITY APOTHECARY LTD
Other - Org Name:THE APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-822-2424
Mailing Address - Street 1:1470 WEBB ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-9187
Mailing Address - Country:US
Mailing Address - Phone:715-822-2424
Mailing Address - Fax:715-822-5470
Practice Address - Street 1:1470 WEBB ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829-9187
Practice Address - Country:US
Practice Address - Phone:715-822-2424
Practice Address - Fax:715-822-5470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336M0002X, 3336L0003X
WI9490-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2112695OtherPK
WI1851390496Medicaid
2112695OtherPK