Provider Demographics
NPI:1407186141
Name:COMMUNITY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL
Other - Org Name:CMH PRIMARY CARE CLINIC, REMOTE DISPENSING REGISTRATION
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:E
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-846-3444
Mailing Address - Street 1:340 N GREEN BAY AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETT
Mailing Address - State:WI
Mailing Address - Zip Code:54124-9325
Mailing Address - Country:US
Mailing Address - Phone:920-855-2823
Mailing Address - Fax:920-855-6343
Practice Address - Street 1:340 N GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:GILLETT
Practice Address - State:WI
Practice Address - Zip Code:54124-9325
Practice Address - Country:US
Practice Address - Phone:920-855-2823
Practice Address - Fax:920-855-6343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
FC1283744OtherDEA REGISTRATION NUMBER