Healthcare Provider Details

I. General information

NPI: 1205969102
Provider Name (Legal Business Name): CARL JEFFREY ELIASON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 BELKNAP ST
SUPERIOR WI
54880-2856
US

IV. Provider business mailing address

1124 BELKNAP ST
SUPERIOR WI
54880-2856
US

V. Phone/Fax

Practice location:
  • Phone: 715-394-7765
  • Fax: 715-394-7765
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10055040
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number7047042
License Number StateWI

VIII. Authorized Official

Name: MR. CARL JEFF ELIASON
Title or Position: OWNER PHARMACIST
Credential: PHARMACIST
Phone: 715-394-7765