Provider Demographics
NPI:1356352850
Name:MANITOWOC PHARMACIES INC
Entity type:Organization
Organization Name:MANITOWOC PHARMACIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:RESCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-253-2164
Mailing Address - Street 1:919 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4504
Mailing Address - Country:US
Mailing Address - Phone:920-684-6789
Mailing Address - Fax:920-684-7041
Practice Address - Street 1:919 S 8TH ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4504
Practice Address - Country:US
Practice Address - Phone:920-684-6789
Practice Address - Fax:920-684-7041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI4907-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33097000Medicaid
2134084OtherPK
WI33097000Medicaid