1093889396 NPI number — RIVER RUN PHARMACIES, INC

Table of content: (NPI 1093889396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093889396 NPI number — RIVER RUN PHARMACIES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVER RUN PHARMACIES, INC
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:
CENTRAL WISCONSIN PHARMACY -MONTELLO
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:
1093889396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 159
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTELLO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53949-0159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-297-2474
Provider Business Mailing Address Fax Number:
608-296-2184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 W MONTELLO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTELLO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53949-0366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-297-2474
Provider Business Practice Location Address Fax Number:
608-716-3159
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACHTHUBER
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
608-297-7452

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 4820-42 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1093889396 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2112889 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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