Provider Demographics
NPI:1982707089
Name:THEDACARE, INCORPORATED
Entity type:Organization
Organization Name:THEDACARE, INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRINI
Authorized Official - Middle Name:
Authorized Official - Last Name:SENZIG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:715-524-1464
Mailing Address - Street 1:100 COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-7072
Mailing Address - Country:US
Mailing Address - Phone:715-526-3456
Mailing Address - Fax:715-524-5627
Practice Address - Street 1:100 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-7072
Practice Address - Country:US
Practice Address - Phone:715-526-3456
Practice Address - Fax:715-524-5627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8673-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2114258OtherPK
WI33239800Medicaid
WI33239800Medicaid