Provider Demographics
NPI:1174689616
Name:CORCORAN HEALTHCARE ENTERPRISES, INC
Entity Type:Organization
Organization Name:CORCORAN HEALTHCARE ENTERPRISES, INC
Other - Org Name:REEDSBURG FAMILY PRESCRIPTION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KISSACK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-524-3215
Mailing Address - Street 1:115 2ND ST
Mailing Address - Street 2:PO BOX 245
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-1602
Mailing Address - Country:US
Mailing Address - Phone:608-524-3215
Mailing Address - Fax:608-524-8410
Practice Address - Street 1:115 2ND ST
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1602
Practice Address - Country:US
Practice Address - Phone:608-524-3215
Practice Address - Fax:608-524-8410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI110773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33168300Medicaid