Provider Demographics
NPI:1982649760
Name:YELLOW RIVER PHARMACY INC
Entity Type:Organization
Organization Name:YELLOW RIVER PHARMACY INC
Other - Org Name:YELLOW RIVER PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAFFEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:715-866-8644
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:WI
Mailing Address - Zip Code:54893-0026
Mailing Address - Country:US
Mailing Address - Phone:715-866-8644
Mailing Address - Fax:715-866-7344
Practice Address - Street 1:7438 MAIN ST W
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-8206
Practice Address - Country:US
Practice Address - Phone:715-866-8644
Practice Address - Fax:715-866-7344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336M0002X
WI88060423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2113263OtherPK
MN273613000Medicaid
WI36223500Medicaid
6092300001Medicare NSC