1811201874 NPI number — JESSICA STORCK PHARMD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811201874 NPI number — JESSICA STORCK PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STORCK
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'LAUGHLIN
Provider Other First Name:
JESSICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811201874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
242 W CHURCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53508-9332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-469-7430
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 22ND AVE
Provider Second Line Business Practice Location Address:
PHARMACY DEPARTMENT
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53566-1569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-324-3111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P1200X , with the licence number:  15668-40 , 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)