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Organization
DEN DIA IV
Active
Organization
DEN DIA IV
Active
Other names
STOWE DRUG STORE
Organization subpart
No
Provider details
NPI number
Authorized official
DENNIS LARSON RPH (PRESIDENT AND PHARMACIST)
(920) 336-6128
Entity
Organization
Contact information
Practice address
375 MAIN AVE, DE PERE, WI 54115-2202
(920) 336-6128
Mailing address
375 MAIN AVE, DE PERE, WI 54115-2202
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
NULL
3336C0003X
Community/Retail Pharmacy
Primary
6162042
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
33055200
—
WI
01
—
5103332
OTHER ID NUMBER-COMMERCIAL NUMBER
—
Enumeration date
04/25/2007
Last updated
09/12/2007
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