Provider Demographics
NPI:1073528675
Name:WAUKESHA HEALTH SYSTEM, INC
Entity Type:Organization
Organization Name:WAUKESHA HEALTH SYSTEM, INC
Other - Org Name:PROHEALTH PHARMACY - WAUKESHA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REIMBURSEMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-928-4704
Mailing Address - Street 1:725 AMERICAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5031
Mailing Address - Country:US
Mailing Address - Phone:262-928-2279
Mailing Address - Fax:262-544-0928
Practice Address - Street 1:725 AMERICAN AVE STE 2309
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:262-928-2279
Practice Address - Fax:262-544-0928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI6694423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2113659OtherPK
WI33154500Medicaid
0200300001Medicare NSC