Provider Demographics
NPI:1104827146
Name:STREU'S PHARMACY, INC
Entity Type:Organization
Organization Name:STREU'S PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIRCHNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:920-437-0206
Mailing Address - Street 1:635 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4918
Mailing Address - Country:US
Mailing Address - Phone:920-437-0206
Mailing Address - Fax:920-884-6932
Practice Address - Street 1:635 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4918
Practice Address - Country:US
Practice Address - Phone:920-437-0206
Practice Address - Fax:920-884-6932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-01
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4744-042333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33073500Medicaid
WI33073500Medicaid
WI0159290001Medicare ID - Type UnspecifiedMEDICARE IDENTIFICATION