MEDICARE: BENZER WI 1 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	9302-42	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2151001	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912997081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENZER WI 1 LLC

Provider Business Mailing Address
First Line	:	1008 MAIN STREET
Second Line	:
City	:	OCONTO
State	:	WI
Zip	:	54153
Country	:	US
Telephone Number	:	813-304-2221
Fax Number	:	888-239-8423

Provider Business Practice Location Address
First Line	:	1008 MAIN ST
Second Line	:
City	:	OCONTO
State	:	WI
Zip	:	54153
Country	:	US
Telephone Number	:	920-834-4455
Fax Number	:	920-834-3655

Authorized Official
Title or Position	:	OWNER
Name	:	BHARGAVI PATEL
Credential	:
Telephone Number	:	810-348-3003

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	05/13/2021

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