Healthcare Provider Details

I. General information

NPI: 1033210638
Provider Name (Legal Business Name): LUCK PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 S MAIN ST
LUCK WI
54853
US

IV. Provider business mailing address

PO BOX 172
LUCK WI
54853-0172
US

V. Phone/Fax

Practice location:
  • Phone: 715-472-2122
  • Fax: 715-472-4423
Mailing address:
  • Phone: 801-716-4857
  • Fax: 801-716-4872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number8365-42
License Number StateWI

VIII. Authorized Official

Name: JENNA CLEMENSON
Title or Position: PHARMACY MANAGER
Credential:
Phone: 715-472-2122