Healthcare Provider Details

I. General information

NPI: 1144384629
Provider Name (Legal Business Name): FALL CREEK PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 E LINCOLN AVE
FALL CREEK WI
54742-9526
US

IV. Provider business mailing address

119 E LINCOLN AVE PO BOX 217
FALL CREEK WI
54742-9526
US

V. Phone/Fax

Practice location:
  • Phone: 715-877-2994
  • Fax: 715-877-3248
Mailing address:
  • Phone: 715-877-2994
  • Fax: 715-877-3248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number8903042
License Number StateWI

VIII. Authorized Official

Name: MISS REBECCA J STONER
Title or Position: RPH /STORE MANAGER
Credential: RPH
Phone: 715-877-2994