=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730841115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINONA PHARMACIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2021
-----------------------------------------------------
Last Update Date | 10/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 FILER AVE STE 2
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-4485
-----------------------------------------------------
Fax | 208-733-4186
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 615 FILER AVE STE 2
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-4485
-----------------------------------------------------
Fax | 208-733-4186
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/RPH
-----------------------------------------------------
Name | DANIEL S FUCHS
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 208-733-4485
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336M0002X
-----------------------------------------------------
Taxonomy Name | Mail Order Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------