Provider Demographics
NPI:1396049706
Name:LTC RX INC
Entity type:Organization
Organization Name:LTC RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-723-9192
Mailing Address - Street 1:13 E SPRUCE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-2579
Mailing Address - Country:US
Mailing Address - Phone:715-861-4422
Mailing Address - Fax:715-861-5141
Practice Address - Street 1:13 E SPRUCE ST STE 102
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2579
Practice Address - Country:US
Practice Address - Phone:715-861-4422
Practice Address - Fax:715-861-5141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 332B00000X, 333600000X, 3336M0003X
WI9055-0423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2129386OtherPK
WI100013800Medicaid