Provider Demographics
NPI:1255414330
Name:WAARVIK DRUG INC
Entity type:Organization
Organization Name:WAARVIK DRUG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROLD
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-284-4354
Mailing Address - Street 1:109 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1748
Mailing Address - Country:US
Mailing Address - Phone:715-284-4354
Mailing Address - Fax:715-284-9053
Practice Address - Street 1:109 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1748
Practice Address - Country:US
Practice Address - Phone:715-284-4354
Practice Address - Fax:715-284-9053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI72900423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33095500Medicaid
0559270001Medicare NSC