Provider Demographics
NPI:1093429821
Name:CUMBERLAND MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:CUMBERLAND MEMORIAL HOSPITAL, INC
Other - Org Name:MAPLE RIDGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-822-7252
Mailing Address - Street 1:1705 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-8601
Mailing Address - Country:US
Mailing Address - Phone:715-822-7222
Mailing Address - Fax:715-822-7111
Practice Address - Street 1:1705 16TH AVE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829
Practice Address - Country:US
Practice Address - Phone:715-822-7548
Practice Address - Fax:715-822-7111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CUMBERLAND MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-06
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10002OtherWISCONSIN STATE PHARMACY LICENSE