Healthcare Provider Details

I. General information

NPI: 1245335835
Provider Name (Legal Business Name): NORTHBAY PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 N 4TH ST P.O. 228
TOMAHAWK WI
54487-2123
US

IV. Provider business mailing address

686 N 4TH ST P.O. 228
TOMAHAWK WI
54487-2123
US

V. Phone/Fax

Practice location:
  • Phone: 715-453-5996
  • Fax: 715-453-4508
Mailing address:
  • Phone: 715-453-5996
  • Fax: 715-453-4508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number6710-042
License Number StateWI

VIII. Authorized Official

Name: WILLIAM RAY DREGER
Title or Position: PHARMACIST
Credential: R.PH.
Phone: 715-453-5996