Provider Demographics
NPI: | 1467906636 |
---|---|
Name: | MONROE HOMETOWN PHARMACY LLC |
Entity Type: | Organization |
Organization Name: | MONROE HOMETOWN PHARMACY LLC |
Other - Org Name: | MONROE HOMETOWN PHARMACY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CONTRACTING |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DIANE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | DEANS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 920-992-6800 |
Mailing Address - Street 1: | 333 LOWVILLE RD |
Mailing Address - Street 2: | |
Mailing Address - City: | RIO |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 53960-9437 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 920-992-6800 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1008 17TH AVE |
Practice Address - Street 2: | |
Practice Address - City: | MONROE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53566-2005 |
Practice Address - Country: | US |
Practice Address - Phone: | 608-325-2151 |
Practice Address - Fax: | 608-325-2153 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-08-05 |
Last Update Date: | 2019-12-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | 100064685 | Medicaid |