Provider Demographics
NPI:1295847119
Name:THE PHARMACY OF NEW LONDON INC.
Entity Type:Organization
Organization Name:THE PHARMACY OF NEW LONDON INC.
Other - Org Name:JERNEGAN'S HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:JERNEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-982-7670
Mailing Address - Street 1:1301 MILL ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2153
Mailing Address - Country:US
Mailing Address - Phone:920-982-7670
Mailing Address - Fax:920-982-7686
Practice Address - Street 1:1301 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2153
Practice Address - Country:US
Practice Address - Phone:920-982-7670
Practice Address - Fax:920-982-7686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6861333600000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33152900Medicaid
5118698OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WIBM1209370OtherDEA #
WIBM1209370OtherDEA #