Provider Demographics
NPI:1265474738
Name:DOOR COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:DOOR COUNTY MEMORIAL HOSPITAL
Other - Org Name:DOOR COUNTY MEDICAL CENTER SISTER BAY REMOTE DISPENSING SITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:S
Authorized Official - Last Name:LALUZERNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-746-3729
Mailing Address - Street 1:323 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1401
Mailing Address - Country:US
Mailing Address - Phone:920-743-5566
Mailing Address - Fax:
Practice Address - Street 1:2345 CANTERBURY LANE
Practice Address - Street 2:
Practice Address - City:SISTER BAY
Practice Address - State:WI
Practice Address - Zip Code:54234
Practice Address - Country:US
Practice Address - Phone:920-746-3633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0003X
WI71203336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5111579OtherNCPDP PROVIDER IDENTIFICATION NUMBER