Provider Demographics
NPI:1336295245
Name:MIDE INC.
Entity Type:Organization
Organization Name:MIDE INC.
Other - Org Name:WOLF RIVER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:RETZLAFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-478-3369
Mailing Address - Street 1:600 E PIONEER ST
Mailing Address - Street 2:
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-1662
Mailing Address - Country:US
Mailing Address - Phone:715-478-3369
Mailing Address - Fax:715-478-3945
Practice Address - Street 1:600 E PIONEER ST
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-1662
Practice Address - Country:US
Practice Address - Phone:715-478-3369
Practice Address - Fax:715-478-3945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7069042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33134200Medicaid
WI33134200Medicaid