Provider Demographics
NPI:1932328242
Name:DEN DIA IV
Entity Type:Organization
Organization Name:DEN DIA IV
Other - Org Name:STOWE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-336-6128
Mailing Address - Street 1:375 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2202
Practice Address - Country:US
Practice Address - Phone:920-336-6128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI61620423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5103332OtherOTHER ID NUMBER
5103332OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI33055200Medicaid
5103332OtherOTHER ID NUMBER