Provider Demographics
NPI:1376615575
Name:KAUKAUNA PRESCRIPTION CENTER
Entity Type:Organization
Organization Name:KAUKAUNA PRESCRIPTION CENTER
Other - Org Name:CONSUMER PRESCRIPTION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLENFANG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-766-9200
Mailing Address - Street 1:200 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-2524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 E 2ND ST
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-2524
Practice Address - Country:US
Practice Address - Phone:920-766-9200
Practice Address - Fax:920-766-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8079042333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5112393OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI33127100Medicaid