Provider Demographics
NPI:1356863252
Name:UVANTA PHARMACY LLC
Entity Type:Organization
Organization Name:UVANTA PHARMACY LLC
Other - Org Name:UVANTA PHARMACY - FOX VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-739-6104
Mailing Address - Street 1:1050 S GRIDER ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-4800
Mailing Address - Country:US
Mailing Address - Phone:920-257-2411
Mailing Address - Fax:866-924-9688
Practice Address - Street 1:1050 S GRIDER ST
Practice Address - Street 2:SUITE C
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914
Practice Address - Country:US
Practice Address - Phone:920-257-2411
Practice Address - Fax:866-924-9688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-12
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
WI9466-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2170173OtherPK
WI100069413Medicaid