Provider Demographics
NPI:1003914045
Name:MOUNT HOREB FAMILY PHARMACY LLC
Entity Type:Organization
Organization Name:MOUNT HOREB FAMILY PHARMACY LLC
Other - Org Name:MOUNT HOREB FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WEILAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-437-3001
Mailing Address - Street 1:203 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-1914
Mailing Address - Country:US
Mailing Address - Phone:608-437-3001
Mailing Address - Fax:608-437-6480
Practice Address - Street 1:203 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-1914
Practice Address - Country:US
Practice Address - Phone:608-437-3001
Practice Address - Fax:608-437-6480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WI8354423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2112892OtherPK
K300846024OtherMEDICARE PTAN
WI33271700Medicaid