Provider Demographics
NPI:1346227642
Name:BLACK RIVER FALLS CLINIC PHARMACY, INC.
Entity Type:Organization
Organization Name:BLACK RIVER FALLS CLINIC PHARMACY, INC.
Other - Org Name:CLINIC PHARMACY OF BLACK RIVER FALLS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAGENBROCK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-284-4089
Mailing Address - Street 1:610 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-9010
Mailing Address - Country:US
Mailing Address - Phone:715-284-4089
Mailing Address - Fax:715-284-1606
Practice Address - Street 1:610 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-9010
Practice Address - Country:US
Practice Address - Phone:715-284-4089
Practice Address - Fax:715-284-1606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6945183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33160900Medicaid
WI33160900Medicaid