Provider Demographics
NPI:1356413850
Name:SHELL LAKE PHARMACY LTD
Entity type:Organization
Organization Name:SHELL LAKE PHARMACY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-418-3478
Mailing Address - Street 1:PO BOX 343
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-0343
Mailing Address - Country:US
Mailing Address - Phone:715-468-7800
Mailing Address - Fax:715-468-7921
Practice Address - Street 1:113 4TH AVE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-4457
Practice Address - Country:US
Practice Address - Phone:715-468-7800
Practice Address - Fax:715-468-7921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6461042332B00000X
3336L0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33038100Medicaid
WI33038100Medicaid