Provider Demographics
NPI:1548372261
Name:FOND DU LAC PRESCRIPTION CENTER, LTD
Entity type:Organization
Organization Name:FOND DU LAC PRESCRIPTION CENTER, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-923-1260
Mailing Address - Street 1:52 SHEBOYGAN ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 SHEBOYGAN ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4220
Practice Address - Country:US
Practice Address - Phone:920-923-1260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5390332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33135600Medicaid
WI0183420001Medicare ID - Type Unspecified