Provider Demographics
NPI:1083935233
Name:JAT PHARMACY, LLC
Entity Type:Organization
Organization Name:JAT PHARMACY, LLC
Other - Org Name:JAT PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY/PHARMACIST IN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARTKOWIAK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MBA
Authorized Official - Phone:877-490-3577
Mailing Address - Street 1:805 BURTON BOULEVARD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532
Mailing Address - Country:US
Mailing Address - Phone:877-490-3577
Mailing Address - Fax:877-490-3576
Practice Address - Street 1:805 BURTON BOULEVARD
Practice Address - Street 2:SUITE A
Practice Address - City:DEFOREST
Practice Address - State:WI
Practice Address - Zip Code:53532
Practice Address - Country:US
Practice Address - Phone:877-490-3577
Practice Address - Fax:877-490-3576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9015-423336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125332OtherPK