Provider Demographics
NPI:1407932536
Name:SSM HEALTH CARE OF WISCONSIN, INC.
Entity Type:Organization
Organization Name:SSM HEALTH CARE OF WISCONSIN, INC.
Other - Org Name:ST MARYS CARE CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUFENACHT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:608-845-0447
Mailing Address - Street 1:3401 MAPLE GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-5013
Mailing Address - Country:US
Mailing Address - Phone:608-845-0447
Mailing Address - Fax:608-845-0449
Practice Address - Street 1:3401 MAPLE GROVE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-5013
Practice Address - Country:US
Practice Address - Phone:608-845-0447
Practice Address - Fax:608-845-0449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8247-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33241000Medicaid
2115167OtherPK