Provider Demographics
NPI:1114070836
Name:SERVICE DRUGS
Entity type:Organization
Organization Name:SERVICE DRUGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HEBL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-742-2808
Mailing Address - Street 1:130 W COOK
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-2104
Mailing Address - Country:US
Mailing Address - Phone:608-742-2808
Mailing Address - Fax:
Practice Address - Street 1:130 W COOK
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-2104
Practice Address - Country:US
Practice Address - Phone:608-742-2808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5463042333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33111200Medicaid
0426800001Medicare ID - Type Unspecified
WI33111200Medicaid