Provider Demographics
NPI:1154321602
Name:BENEVOLENT CORPORATION CEDAR COMMUNITY
Entity Type:Organization
Organization Name:BENEVOLENT CORPORATION CEDAR COMMUNITY
Other - Org Name:CEDAR LAKE CAMPUS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:T
Authorized Official - Last Name:PICHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-306-4212
Mailing Address - Street 1:5595 COUNTY ROAD Z
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9224
Mailing Address - Country:US
Mailing Address - Phone:262-306-2140
Mailing Address - Fax:262-306-2141
Practice Address - Street 1:5595 COUNTY ROAD Z
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9224
Practice Address - Country:US
Practice Address - Phone:262-306-2140
Practice Address - Fax:262-306-2141
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENEVOLENT CORPORATION CEDAR COMMUNITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-27
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5115503333600000X, 3336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33027100Medicaid
WI0530970001Medicare NSC