Provider Demographics
NPI:1952477903
Name:ELLSWORTH VILLAGE PHARMACY INC.
Entity Type:Organization
Organization Name:ELLSWORTH VILLAGE PHARMACY INC.
Other - Org Name:VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCHULZE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-273-4466
Mailing Address - Street 1:183 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011-9188
Mailing Address - Country:US
Mailing Address - Phone:715-273-4466
Mailing Address - Fax:715-273-5414
Practice Address - Street 1:183 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011-9188
Practice Address - Country:US
Practice Address - Phone:715-273-4466
Practice Address - Fax:715-273-5414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8321-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33052400Medicaid
5111062OtherNABP
5111062OtherNABP