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General NPI Number Information
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NPI Number | 1205969102
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Entity Type | Organization
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Legal Business Name | CARL JEFFREY ELIASON
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Dates
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Enumeration Date | 03/13/2007
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Last Update Date | 09/05/2008
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Provider Practice Location Address
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Address Line | 1124 BELKNAP ST
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City | SUPERIOR
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State | WI
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Zip | 54880-2856
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Country | US
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Telephone | 715-394-7765
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Fax | 715-394-7765
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Provider Business Mailing Address
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Address Line | 1124 BELKNAP ST
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City | SUPERIOR
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State | WI
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Zip | 54880-2856
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER PHARMACIST
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Name | MR. CARL JEFF ELIASON
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Credential | PHARMACIST
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Telephone | 715-394-7765
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 7047042
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 10055040
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License Number State | WI
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