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?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100064685Medicaid