Healthcare Provider Details

I. General information

NPI: 1356413850
Provider Name (Legal Business Name): SHELL LAKE PHARMACY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 4TH AVE
SHELL LAKE WI
54871-4457
US

IV. Provider business mailing address

PO BOX 343
SHELL LAKE WI
54871-0343
US

V. Phone/Fax

Practice location:
  • Phone: 715-468-7800
  • Fax: 715-468-7921
Mailing address:
  • Phone: 715-468-7800
  • Fax: 715-468-7921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number6461042
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PAIGE WILES
Title or Position: ADMIN ASSISTANT
Credential:
Phone: 715-418-3478