Provider Demographics
NPI:1174815237
Name:ERICKSON PHARMACY LLC
Entity Type:Organization
Organization Name:ERICKSON PHARMACY LLC
Other - Org Name:ERICKSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HASHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAIBAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-712-5200
Mailing Address - Street 1:8 S MAIN ST
Mailing Address - Street 2:STE B
Mailing Address - City:CLINTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54929-1565
Mailing Address - Country:US
Mailing Address - Phone:715-823-2106
Mailing Address - Fax:715-823-1322
Practice Address - Street 1:8 S MAIN ST
Practice Address - Street 2:STE B
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1565
Practice Address - Country:US
Practice Address - Phone:715-823-2222
Practice Address - Fax:715-823-6000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-09
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI907423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130012OtherPK
WI117815237Medicaid