Provider Demographics
NPI:1922044411
Name:NORTHERN LAKES COOPERATIVE
Entity Type:Organization
Organization Name:NORTHERN LAKES COOPERATIVE
Other - Org Name:CO-OP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COVELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-634-3211
Mailing Address - Street 1:15846 W US HIGHWAY 63 S
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-0985
Mailing Address - Country:US
Mailing Address - Phone:715-634-8238
Mailing Address - Fax:715-634-8170
Practice Address - Street 1:15846 W US HIGHWAY 63 S
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-7106
Practice Address - Country:US
Practice Address - Phone:715-634-8238
Practice Address - Fax:715-634-8170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI7348-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115372OtherPK
WI33197400Medicaid
WI33197400Medicaid