Provider Demographics
NPI:1992113815
Name:IN THE WOODS APOTHECARY
Entity type:Organization
Organization Name:IN THE WOODS APOTHECARY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:715-349-2221
Mailing Address - Street 1:24106 STATE RD 35
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872
Mailing Address - Country:US
Mailing Address - Phone:715-349-2221
Mailing Address - Fax:
Practice Address - Street 1:24106 STATE RD 35
Practice Address - Street 2:
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872
Practice Address - Country:US
Practice Address - Phone:715-349-2221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy