Healthcare Provider Details

I. General information

NPI: 1578644639
Provider Name (Legal Business Name): HAWKEYE ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24106 STATE ROAD 35
SIREN WI
54872-0000
US

IV. Provider business mailing address

24106 STATE ROAD 35
SIREN WI
54872
US

V. Phone/Fax

Practice location:
  • Phone: 715-349-2221
  • Fax: 715-349-7350
Mailing address:
  • Phone: 715-349-2221
  • Fax: 715-349-7350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number8102-042
License Number StateWI

VIII. Authorized Official

Name: MR. THOMAS W MOORE
Title or Position: OWNER
Credential: R.PH.
Phone: 715-349-2221