Basic Information
| Provider Information | |||||||||
| NPI: | 1912997081 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BENZER WI 1 LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OCONTO PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | OCONTO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133042221 | ||||||||
| FaxNumber: | 8882398423 | ||||||||
| Practice Location | |||||||||
| Address1: | 1008 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OCONTO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208344455 | ||||||||
| FaxNumber: | 9208343655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | BHARGAVI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8103483003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 9302-42 | WI | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2151001 | 01 | PK | OTHER | 33009500 | 05 | WI | MEDICAID |