Provider Demographics
NPI:1316380785
Name:FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC
Entity Type:Organization
Organization Name:FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRIZD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:262-532-5168
Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3462
Mailing Address - Country:US
Mailing Address - Phone:414-955-5990
Mailing Address - Fax:
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3462
Practice Address - Country:US
Practice Address - Phone:414-955-5990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336S0011X
WI9196-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139864OtherPK