Provider Demographics
NPI:1417156209
Name:H1 LACROSSE LLC
Entity Type:Organization
Organization Name:H1 LACROSSE LLC
Other - Org Name:UVANTA PHARMACY OF LACROSSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:VANSTRATEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-347-9405
Mailing Address - Street 1:2840 21ST PL S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7302
Mailing Address - Country:US
Mailing Address - Phone:608-784-6500
Mailing Address - Fax:608-784-6504
Practice Address - Street 1:2840 21ST PL S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7302
Practice Address - Country:US
Practice Address - Phone:608-784-6500
Practice Address - Fax:608-784-6504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI87500423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5130024OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI33299800Medicaid