Provider Demographics
NPI:1073580403
Name:METHODIST MANOR HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:METHODIST MANOR HEALTH CENTER, INC.
Other - Org Name:MANOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ENLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-607-4100
Mailing Address - Street 1:3023 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-3703
Mailing Address - Country:US
Mailing Address - Phone:414-607-4100
Mailing Address - Fax:414-607-4502
Practice Address - Street 1:8615 W BELOIT RD
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-3711
Practice Address - Country:US
Practice Address - Phone:414-607-2165
Practice Address - Fax:414-607-4507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6309333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5116187OtherNCPDP NUMBER
WI6309OtherSTATE LICENSE NUMBER
WI33028500Medicaid
WI33028500Medicaid
WIAM1036739OtherDEA NUMBER
WIAM1036739OtherDEA NUMBER