1871059626 NPI number — MONROE HOMETOWN PHARMACY WEST LLC

Table of content: (NPI 1871059626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871059626 NPI number — MONROE HOMETOWN PHARMACY WEST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONROE HOMETOWN PHARMACY WEST 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:
MONROE HOMETOWN PHARMACY WEST
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:
1871059626
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2022
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:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 W 7TH ST UNIT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53566-3716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-426-6540
Provider Business Practice Location Address Fax Number:
608-426-6561
Provider Enumeration Date:
02/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
STOCKS
Authorized Official First Name:
HALEY
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTRACTING SPECIALIST
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: 3336C0003X ; 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: 100086153 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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