1053862318 NPI number — WAUNAKEE HOMETOWN PHARMACY LLC

Table of content: (NPI 1053862318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053862318 NPI number — WAUNAKEE HOMETOWN PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAUNAKEE HOMETOWN PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WAUNAKEE HOMETOWN PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053862318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 LOWVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53960-9437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-992-6800
Provider Business Mailing Address Fax Number:
920-992-6800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 S CENTURY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUNAKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53597-1249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-850-9314
Provider Business Practice Location Address Fax Number:
608-850-9501
Provider Enumeration Date:
10/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
STRAUSE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
920-992-6800

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 9430-42 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2165812 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100063545 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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