Provider Demographics
NPI:1174187827
Name:WAUTOMA HOMETOWN PHARMACY LLC
Entity Type:Organization
Organization Name:WAUTOMA HOMETOWN PHARMACY LLC
Other - Org Name:WAUTOMA HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOCKS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:920-992-6800
Mailing Address - Street 1:333 LOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RIO
Mailing Address - State:WI
Mailing Address - Zip Code:53960-9437
Mailing Address - Country:US
Mailing Address - Phone:920-992-6800
Mailing Address - Fax:920-992-6801
Practice Address - Street 1:W7810 STATE ROAD 21 STE B
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-7702
Practice Address - Country:US
Practice Address - Phone:920-787-9561
Practice Address - Fax:920-787-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100088330Medicaid