Provider Demographics
NPI:1962480707
Name:STOXEN PHARMACY
Entity Type:Organization
Organization Name:STOXEN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CORLISS
Authorized Official - Middle Name:J
Authorized Official - Last Name:STOXEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-361-4770
Mailing Address - Street 1:12 W WISCONSIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487
Mailing Address - Country:US
Mailing Address - Phone:715-453-3110
Mailing Address - Fax:715-453-4469
Practice Address - Street 1:12 W WISCONSIN AVENUE
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487
Practice Address - Country:US
Practice Address - Phone:715-453-3110
Practice Address - Fax:715-453-4469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6389333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33082200Medicaid
WI0251030001Medicare NSC