Provider Demographics
NPI:1912997081
Name:BENZER WI 1 LLC
Entity Type:Organization
Organization Name:BENZER WI 1 LLC
Other - Org Name:OCONTO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BHARGAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-348-3003
Mailing Address - Street 1:1008 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153
Mailing Address - Country:US
Mailing Address - Phone:813-304-2221
Mailing Address - Fax:888-239-8423
Practice Address - Street 1:1008 MAIN ST
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153
Practice Address - Country:US
Practice Address - Phone:920-834-4455
Practice Address - Fax:920-834-3655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9302-423336C0003X
WI7540-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151001OtherPK
WI33009500Medicaid
WI33009500Medicaid