Provider Demographics
NPI:1073526661
Name:GUNDERSEN CLINIC LTD
Entity Type:Organization
Organization Name:GUNDERSEN CLINIC LTD
Other - Org Name:GUNDERSEN PHARMACY - LA CROSSE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-775-6369
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-775-5595
Mailing Address - Fax:608-775-4445
Practice Address - Street 1:1836 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5429
Practice Address - Country:US
Practice Address - Phone:608-775-5595
Practice Address - Fax:608-775-4445
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUNDERSEN CLINIC LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-14
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4884333600000X
MN2632083336C0002X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2112770OtherPK
WI33096300Medicaid