Provider Demographics
NPI:1679696421
Name:DEAN RETAIL SERVICES, INC.
Entity type:Organization
Organization Name:DEAN RETAIL SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT-FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-260-3586
Mailing Address - Street 1:3200 E RACINE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2343
Mailing Address - Country:US
Mailing Address - Phone:608-371-8000
Mailing Address - Fax:608-371-8834
Practice Address - Street 1:3200 E RACINE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2343
Practice Address - Country:US
Practice Address - Phone:608-371-8000
Practice Address - Fax:608-371-8834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100048656Medicaid
WI100048656Medicaid