Provider Demographics
NPI:1891866802
Name:REESEVILLE VILLAGE PHARMACY LLC
Entity Type:Organization
Organization Name:REESEVILLE VILLAGE PHARMACY LLC
Other - Org Name:VILLAGE HEALTHMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DYKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH,
Authorized Official - Phone:920-927-3305
Mailing Address - Street 1:202 S. MAIN ST.
Mailing Address - Street 2:P.O. BOX 87
Mailing Address - City:REESEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53579-0087
Mailing Address - Country:US
Mailing Address - Phone:920-927-3305
Mailing Address - Fax:920-927-3307
Practice Address - Street 1:202 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:REESEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53579-0087
Practice Address - Country:US
Practice Address - Phone:920-927-3305
Practice Address - Fax:920-927-3307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5761-042333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33098800Medicaid
WI5109005OtherNCPDP NUMBER
WI33098800Medicaid