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
—
—
3336C0003X
Community/Retail Pharmacy
Primary
6162042
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
33055200
—
WI
01
—
5103332
OTHER ID NUMBER
—
Enumeration date
04/25/2007
Last updated
09/12/2007
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