Provider Demographics
NPI:1326608142
Name:KEWAUNEE HOMETOWN PHARMACY LLC
Entity Type:Organization
Organization Name:KEWAUNEE HOMETOWN PHARMACY LLC
Other - Org Name:KEWAUNEE HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOCKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-992-6800
Mailing Address - Street 1:333 LOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RIO
Mailing Address - State:WI
Mailing Address - Zip Code:53960-9437
Mailing Address - Country:US
Mailing Address - Phone:920-992-6800
Mailing Address - Fax:920-992-6801
Practice Address - Street 1:1614 CENTER ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1792
Practice Address - Country:US
Practice Address - Phone:920-310-1616
Practice Address - Fax:920-388-6164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-14
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100090741Medicaid