Provider Demographics
NPI:1346251840
Name:GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN
Entity Type:Organization
Organization Name:GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN
Other - Org Name:GHC SAUK TRAILS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATION COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLAGEL DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-828-4811
Mailing Address - Street 1:PO BOX 44971
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53744-4971
Mailing Address - Country:US
Mailing Address - Phone:608-828-4811
Mailing Address - Fax:608-828-4810
Practice Address - Street 1:8202 EXCELSIOR DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1906
Practice Address - Country:US
Practice Address - Phone:608-831-1773
Practice Address - Fax:608-828-4843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
WI7386-423336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2108702OtherPK