Healthcare Provider Details

I. General information

NPI: 1649501586
Provider Name (Legal Business Name): GWIDT PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E WESTGOR AVE SUITE 1
WITTENBERG WI
54499-9174
US

IV. Provider business mailing address

PO BOX 253
WITTENBERG WI
54499-0253
US

V. Phone/Fax

Practice location:
  • Phone: 715-253-2164
  • Fax: 715-253-3030
Mailing address:
  • Phone: 715-253-2164
  • Fax: 715-253-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number8989-42
License Number StateWI

VIII. Authorized Official

Name: SHANE RESCH
Title or Position: VICE-PRESIDENT
Credential:
Phone: 715-253-2164