Provider Demographics
NPI:1912019837
Name:NUTRITIONAL DESIGNS LLC
Entity Type:Organization
Organization Name:NUTRITIONAL DESIGNS LLC
Other - Org Name:NUTRITIONAL DESIGNS AND PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-632-6500
Mailing Address - Street 1:5220 WASHINGTON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4228
Mailing Address - Country:US
Mailing Address - Phone:262-632-6500
Mailing Address - Fax:262-632-6505
Practice Address - Street 1:5220 WASHINGTON AVE STE 101
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4228
Practice Address - Country:US
Practice Address - Phone:262-632-6500
Practice Address - Fax:262-632-6505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9184-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33281600Medicaid
2110287OtherPK