Healthcare Provider Details

I. General information

NPI: 1053459040
Provider Name (Legal Business Name): VILLAGE APOTHECARY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W MAIN ST
CAMPBELLSPORT WI
53010-2704
US

IV. Provider business mailing address

110 W MAIN ST
CAMPBELLSPORT WI
53010-2704
US

V. Phone/Fax

Practice location:
  • Phone: 920-533-4012
  • Fax: 920-533-4012
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5998042
License Number StateWI

VIII. Authorized Official

Name: RONALD GUSSICK
Title or Position: PRESIDENT
Credential: RPH
Phone: 920-533-4012