=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639574932
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CPI MENOMONIE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2014
-----------------------------------------------------
Last Update Date | 02/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1302 STOUT RD
-----------------------------------------------------
City | MENOMONIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54751-2979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-309-4329
-----------------------------------------------------
Fax | 715-309-4326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13 E SPRUCE ST SUITE 102
-----------------------------------------------------
City | CHIPPEWA FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54729-2579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-861-4422
-----------------------------------------------------
Fax | 715-861-7150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER - PRESIDENT
-----------------------------------------------------
Name | PAUL WINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-861-4422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 9288-42
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------