1780794479 NPI number — DEAN RETAIL SERVICES, INC.

Table of content: (NPI 1780794479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780794479 NPI number — DEAN RETAIL SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEAN RETAIL SERVICES, 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:
SSM HEALTH 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:
1780794479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 259443
Provider Second Line Business Mailing Address:
ATTN: SSM HEALTH PHARMACY ADMIN
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53725-9443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-250-1450
Provider Business Mailing Address Fax Number:
608-824-2690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
752 N. HIGH POINT RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53717-2236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-824-4500
Provider Business Practice Location Address Fax Number:
608-824-4928
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRINNELL
Authorized Official First Name:
AMY
Authorized Official Middle Name:
JO
Authorized Official Title or Position:
VP FINANCE
Authorized Official Telephone Number:
608-260-3586

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 33243500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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