Provider Demographics
NPI:1073839114
Name:COMMUNITY HEALTH PHARMACY LLC
Entity Type:Organization
Organization Name:COMMUNITY HEALTH PHARMACY LLC
Other - Org Name:COMMUNITY HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRIESKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-386-9039
Mailing Address - Street 1:P.O. BOX 185
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669
Mailing Address - Country:US
Mailing Address - Phone:608-786-2520
Mailing Address - Fax:
Practice Address - Street 1:880 N. MILL ST.
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669
Practice Address - Country:US
Practice Address - Phone:608-786-2520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-14
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9003-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073839114Medicaid
WI1073839114Medicaid