Provider Demographics
NPI:1093889396
Name:RIVER RUN PHARMACIES, INC
Entity Type:Organization
Organization Name:RIVER RUN PHARMACIES, INC
Other - Org Name:CENTRAL WISCONSIN PHARMACY -MONTELLO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACHTHUBER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:608-297-7452
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:MONTELLO
Mailing Address - State:WI
Mailing Address - Zip Code:53949-0159
Mailing Address - Country:US
Mailing Address - Phone:608-297-2474
Mailing Address - Fax:608-296-2184
Practice Address - Street 1:25 W MONTELLO ST
Practice Address - Street 2:
Practice Address - City:MONTELLO
Practice Address - State:WI
Practice Address - Zip Code:53949-0366
Practice Address - Country:US
Practice Address - Phone:608-297-2474
Practice Address - Fax:608-716-3159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WI4820-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1093889396Medicaid
2112889OtherPK
0219580002Medicare NSC