Provider Demographics
NPI:1871546705
Name:MARINETTE MENOMINEE PRESCRIPTION CENTER LTD
Entity type:Organization
Organization Name:MARINETTE MENOMINEE PRESCRIPTION CENTER LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKE
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:715-732-0717
Mailing Address - Street 1:1378 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-2425
Mailing Address - Country:US
Mailing Address - Phone:715-732-0717
Mailing Address - Fax:715-732-0596
Practice Address - Street 1:1378 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-2425
Practice Address - Country:US
Practice Address - Phone:715-732-0717
Practice Address - Fax:715-732-0596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X, 3336S0011X
WI9392-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1871546705Medicaid
WI9509274Medicaid
2112092OtherPK
WI33114900Medicaid
0293970001Medicare NSC