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General NPI Number Information
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NPI Number | 1932328242
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Entity Type | Organization
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Legal Business Name | DEN DIA IV
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Dates
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Enumeration Date | 04/25/2007
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Last Update Date | 09/12/2007
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Provider Practice Location Address
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Address Line | 375 MAIN AVE
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City | DE PERE
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State | WI
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Zip | 54115-2202
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Country | US
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Telephone | 920-336-6128
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Fax |
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Provider Business Mailing Address
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Address Line | 375 MAIN AVE
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City | DE PERE
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State | WI
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Zip | 54115-2202
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT AND PHARMACIST
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Name | DENNIS LARSON
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Credential | RPH
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Telephone | 920-336-6128
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 6162042
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License Number State | WI
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