Provider Demographics
NPI:1114994209
Name:ASCENSION WISCONSIN PHARMACY, INC.
Entity Type:Organization
Organization Name:ASCENSION WISCONSIN PHARMACY, INC.
Other - Org Name:ASCENSION RX 1104
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-465-3090
Mailing Address - Street 1:PO BOX 860011
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0011
Mailing Address - Country:US
Mailing Address - Phone:262-780-4430
Mailing Address - Fax:262-780-4440
Practice Address - Street 1:19333 W NORTH AVE
Practice Address - Street 2:SUITE 390
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4132
Practice Address - Country:US
Practice Address - Phone:262-780-4430
Practice Address - Fax:262-780-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
WI8462423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2110236OtherPK
WI33280000Medicaid
WI33280000Medicaid