Provider Demographics
NPI:1073536967
Name:ST CLARE MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:ST CLARE MEMORIAL HOSPITAL, INC.
Other - Org Name:ST CLARE MEMORIAL HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-884-5660
Mailing Address - Street 1:855 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1241
Mailing Address - Country:US
Mailing Address - Phone:920-846-3444
Mailing Address - Fax:920-846-4589
Practice Address - Street 1:855 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1241
Practice Address - Country:US
Practice Address - Phone:920-846-3444
Practice Address - Fax:920-846-4589
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST CLARE MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
WI53390423336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1326349135OtherCMH SB NPI
WI33285700Medicaid
5111745OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI1851477913OtherCMH NPI