Provider Demographics
NPI:1063445278
Name:RED CROSS PHARMACY
Entity Type:Organization
Organization Name:RED CROSS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:HOPP
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-635-2117
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801
Mailing Address - Country:US
Mailing Address - Phone:715-635-2117
Mailing Address - Fax:715-635-8135
Practice Address - Street 1:146 WALNUT STREET
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801
Practice Address - Country:US
Practice Address - Phone:715-635-2117
Practice Address - Fax:715-635-8135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33104200Medicaid
WI33104200Medicaid
0209690001Medicare NSC