Provider Demographics
NPI:1275860785
Name:DAHLSTROMS INC
Entity Type:Organization
Organization Name:DAHLSTROMS INC
Other - Org Name:LAKESIDE MARKET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:O
Authorized Official - Last Name:DAHLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-468-2319
Mailing Address - Street 1:37 5TH AVE
Mailing Address - Street 2:PO BOX 236
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871
Mailing Address - Country:US
Mailing Address - Phone:715-468-2319
Mailing Address - Fax:715-468-4140
Practice Address - Street 1:37 5TH AVE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-0236
Practice Address - Country:US
Practice Address - Phone:715-468-2319
Practice Address - Fax:715-468-4140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site