Provider Demographics
NPI:1417367277
Name:GUNDERSEN CLINIC LTD
Entity Type:Organization
Organization Name:GUNDERSEN CLINIC LTD
Other - Org Name:GUNDERSEN PHARMACY - PRAIRIE DU CHIEN
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-775-6369
Mailing Address - Street 1:610 E TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-2109
Mailing Address - Country:US
Mailing Address - Phone:608-326-8911
Mailing Address - Fax:608-326-3324
Practice Address - Street 1:610 E TAYLOR ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-2109
Practice Address - Country:US
Practice Address - Phone:608-326-8911
Practice Address - Fax:608-326-3324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUNDERSEN CLINIC LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-02
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9258-42333600000X
3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146337OtherPK