Provider Demographics
NPI:1184762791
Name:PAUL LINDERUD
Entity type:Organization
Organization Name:PAUL LINDERUD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER RPH
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDERUD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-478-3313
Mailing Address - Street 1:101 N LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-1386
Mailing Address - Country:US
Mailing Address - Phone:715-478-3313
Mailing Address - Fax:715-478-2065
Practice Address - Street 1:101 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-1386
Practice Address - Country:US
Practice Address - Phone:715-478-3313
Practice Address - Fax:715-478-2065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7364-042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5105552OtherNABP#
WI33196700Medicaid
WI5105552OtherNABP#