Healthcare Provider Details

I. General information

NPI: 1750673919
Provider Name (Legal Business Name): RESTORE HEALTH PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1289 DEMING WAY
MADISON WI
53717-2007
US

IV. Provider business mailing address

1289 DEMING WAY
MADISON WI
53717-2007
US

V. Phone/Fax

Practice location:
  • Phone: 800-558-7046
  • Fax: 888-898-7412
Mailing address:
  • Phone: 800-558-7046
  • Fax: 888-898-7412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number9070-042
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW WANDERER
Title or Position: CEO
Credential: PHARMD
Phone: 480-421-8005