Provider Demographics
NPI:1235151267
Name:WISCONSIN VETERANS HOME PHCY
Entity Type:Organization
Organization Name:WISCONSIN VETERANS HOME PHCY
Other - Org Name:WISCONSIN VETERANS HOME PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHASE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-256-5123
Mailing Address - Street 1:N2665 COUNTY ROAD QQ
Mailing Address - Street 2:
Mailing Address - City:KING
Mailing Address - State:WI
Mailing Address - Zip Code:54946-0600
Mailing Address - Country:US
Mailing Address - Phone:715-258-1674
Mailing Address - Fax:715-258-3327
Practice Address - Street 1:N2665 COUNTY ROAD QQ
Practice Address - Street 2:
Practice Address - City:KING
Practice Address - State:WI
Practice Address - Zip Code:54946-0600
Practice Address - Country:US
Practice Address - Phone:715-258-1674
Practice Address - Fax:715-258-3327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55683336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5112379Medicaid
2113651OtherPK