Provider Demographics
NPI:1407291917
Name:GALESVILLE LTC PHARMAY LLC
Entity Type:Organization
Organization Name:GALESVILLE LTC PHARMAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SWING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-582-2446
Mailing Address - Street 1:PO BOX 493
Mailing Address - Street 2:16814 S MAIN ST
Mailing Address - City:GALESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54630-0493
Mailing Address - Country:US
Mailing Address - Phone:608-582-2446
Mailing Address - Fax:608-582-4321
Practice Address - Street 1:16814 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GALESVILLE
Practice Address - State:WI
Practice Address - Zip Code:54630-7704
Practice Address - Country:US
Practice Address - Phone:608-582-2446
Practice Address - Fax:608-582-4321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-10
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6972350001Medicare NSC