Provider Demographics
NPI:1093804122
Name:CLINIC PHARMACY OF WEST SALEM INC
Entity Type:Organization
Organization Name:CLINIC PHARMACY OF WEST SALEM INC
Other - Org Name:CLINIC PHARMACY GIFTS & MORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:F
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-786-2828
Mailing Address - Street 1:126 LEONARD ST S
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-1621
Mailing Address - Country:US
Mailing Address - Phone:608-786-2828
Mailing Address - Fax:608-786-2845
Practice Address - Street 1:126 LEONARD ST S
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-1621
Practice Address - Country:US
Practice Address - Phone:608-786-2828
Practice Address - Fax:608-786-2845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9040-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33189400Medicaid
WI0937920001Medicare NSC