=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639174980
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELLICOSE INTERNATIONAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2005
-----------------------------------------------------
Last Update Date | 09/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 W MADISON AVE
-----------------------------------------------------
City | GRANTSBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54840-7022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-463-2525
-----------------------------------------------------
Fax | 715-463-5343
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 W MADISON AVE
-----------------------------------------------------
City | GRANTSBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54840-7022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-463-2525
-----------------------------------------------------
Fax | 715-463-5343
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP RDO
-----------------------------------------------------
Name | SELMA DZELIL
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 815-715-8502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 6872
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 6872
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------