Provider Demographics
NPI:1164948816
Name:LUXEMBURG PHARMACY, LLC
Entity Type:Organization
Organization Name:LUXEMBURG PHARMACY, LLC
Other - Org Name:LUXEMBURG PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND RPH
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIDL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-845-5832
Mailing Address - Street 1:125 SCHOOL CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:LUXEMBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54217-1095
Mailing Address - Country:US
Mailing Address - Phone:920-845-5832
Mailing Address - Fax:920-845-5834
Practice Address - Street 1:125 SCHOOL CREEK TRL
Practice Address - Street 2:
Practice Address - City:LUXEMBURG
Practice Address - State:WI
Practice Address - Zip Code:54217-1095
Practice Address - Country:US
Practice Address - Phone:920-845-5832
Practice Address - Fax:920-845-5834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8299-0423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33268500Medicaid
2170832OtherPK