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General NPI Number Information
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NPI Number | 1104002674
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Entity Type | Organization
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Legal Business Name | ALLEN C LANG
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Dates
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Enumeration Date | 01/15/2008
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Last Update Date | 01/16/2008
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Provider Practice Location Address
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Address Line | 210 S MAIN ST
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City | MEDFORD
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State | WI
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Zip | 54451-1843
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Country | US
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Telephone | 715-748-4477
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Fax | 715-748-5848
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Provider Business Mailing Address
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Address Line | 210 S MAIN ST
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City | MEDFORD
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State | WI
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Zip | 54451-1843
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Country | US
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Telephone | 715-748-4477
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Fax | 715-748-5848
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Authorized Official
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Title or Position | OWNER/PHARMACIST
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Name | MR. ALLEN C LANG
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Credential | R.PH.
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Telephone | 715-748-4477
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 6494-42
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License Number State | WI
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