Provider Demographics
NPI:1720193758
Name:WISNER BECK DRUG INC
Entity type:Organization
Organization Name:WISNER BECK DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-695-3511
Mailing Address - Street 1:802 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-1499
Mailing Address - Country:US
Mailing Address - Phone:269-695-3511
Mailing Address - Fax:269-695-7135
Practice Address - Street 1:802 E FRONT ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-1499
Practice Address - Country:US
Practice Address - Phone:269-695-3511
Practice Address - Fax:269-695-7135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010000733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2520322Medicaid
2311013OtherNCPDP PROVIDER IDENTIFICATION NUMBER