Provider Demographics
NPI:1164974036
Name:CORCORAN HEALTHCARE ENT INC
Entity Type:Organization
Organization Name:CORCORAN HEALTHCARE ENT INC
Other - Org Name:RICHLAND FAMILY PRESCRIPTION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:F
Authorized Official - Last Name:CORCORAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-647-8806
Mailing Address - Street 1:301 E 2ND ST
Mailing Address - Street 2:PO BOX 309
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-1900
Mailing Address - Country:US
Mailing Address - Phone:608-647-8806
Mailing Address - Fax:608-647-2029
Practice Address - Street 1:301 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1900
Practice Address - Country:US
Practice Address - Phone:608-647-8806
Practice Address - Fax:608-647-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-26
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7973-042333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB08230661OtherCEDI TRADING PARTNER
WI33168200Medicaid
WI33168200Medicaid