Provider Demographics
NPI:1184045106
Name:HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES INC
Entity Type:Organization
Organization Name:HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES INC
Other - Org Name:HEALTHDIRECT INSTITUTIONAL PHARMACY SERVICES INC #119
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-287-3600
Mailing Address - Street 1:29 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1401
Mailing Address - Country:US
Mailing Address - Phone:315-287-3600
Mailing Address - Fax:315-287-4291
Practice Address - Street 1:1721 MILLER ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5217
Practice Address - Country:US
Practice Address - Phone:608-784-6500
Practice Address - Fax:608-784-6504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-17
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9238-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7082550007Medicare NSC