Provider Demographics
NPI:1932510427
Name:OWEN-WITHEE PHARMACY INC
Entity Type:Organization
Organization Name:OWEN-WITHEE PHARMACY INC
Other - Org Name:OWEN-WITHEE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:PROHASKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-415-1891
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:WITHEE
Mailing Address - State:WI
Mailing Address - Zip Code:54498-0123
Mailing Address - Country:US
Mailing Address - Phone:715-229-2074
Mailing Address - Fax:715-229-2950
Practice Address - Street 1:514 DIVISION ST
Practice Address - Street 2:
Practice Address - City:WITHEE
Practice Address - State:WI
Practice Address - Zip Code:54498-9411
Practice Address - Country:US
Practice Address - Phone:715-229-2020
Practice Address - Fax:715-229-2950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-19
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9261-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145811OtherPK
WI100037997Medicaid
7156150001Medicare NSC