Provider Demographics
NPI:1922043066
Name:WOLLMANS OF VERMILLION
Entity Type:Organization
Organization Name:WOLLMANS OF VERMILLION
Other - Org Name:CHOICE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORP PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NORM
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:605-624-8038
Mailing Address - Street 1:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:FREEMAN
Mailing Address - State:SD
Mailing Address - Zip Code:57029-0120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-1107
Practice Address - Country:US
Practice Address - Phone:605-624-8038
Practice Address - Fax:605-624-8039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1005133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4303967OtherOTHER ID NUMBER-COMMERCIAL NUMBER
SD8504060Medicaid
SD=========00Medicaid
SD8504060Medicaid