Provider Demographics
NPI:1497220693
Name:GUNDERSEN CLINIC LTD
Entity Type:Organization
Organization Name:GUNDERSEN CLINIC LTD
Other - Org Name:GUNDERSEN PHARMACY - SAND LAKE ROAD
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-775-6369
Mailing Address - Street 1:111 SAND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2760
Mailing Address - Country:US
Mailing Address - Phone:608-775-8582
Mailing Address - Fax:
Practice Address - Street 1:111 SAND LAKE RD
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-2760
Practice Address - Country:US
Practice Address - Phone:608-775-8595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUNDERSEN CLINIC LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-04
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy