=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255414330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAARVIK DRUG INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 05/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 MAIN ST
-----------------------------------------------------
City | BLACK RIVER FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54615-1748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-284-4354
-----------------------------------------------------
Fax | 715-284-9053
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 MAIN ST
-----------------------------------------------------
City | BLACK RIVER FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54615-1748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-284-4354
-----------------------------------------------------
Fax | 715-284-9053
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT/PHARMACIST
-----------------------------------------------------
Name | MR. JEROLD R GRASSMAN
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 715-284-4354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 7290042
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------