1730282880 NPI number — CEDARBURG PRESCRIPTION CENTER INC

Table of content: (NPI 1730282880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730282880 NPI number — CEDARBURG PRESCRIPTION CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDARBURG PRESCRIPTION CENTER 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:
Provider Other Organization Name Type Code:
6
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:
1730282880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N54W6135 MILL ST
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
CEDARBURG
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53012-2021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-375-0010
Provider Business Mailing Address Fax Number:
262-375-0080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N54W6135 MILL ST
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
CEDARBURG
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53012-2021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-375-0010
Provider Business Practice Location Address Fax Number:
262-375-0080
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BEYER
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
414-232-4103

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  054.018973 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PH29535 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X , with the licence number: 22-44771 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 7808-42 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2108915 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33233800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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