=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811201742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDFORD PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2010
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 S MAIN ST
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54451-1843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-748-4477
-----------------------------------------------------
Fax | 715-748-5848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 S MAIN ST
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54451-1843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-748-4477
-----------------------------------------------------
Fax | 715-748-5848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMIN ASSISTANT
-----------------------------------------------------
Name | PAIGE WILES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-418-3478
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 9018-42
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------