Provider Demographics
NPI:1497942205
Name:PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL, INC.
Other - Org Name:PROHEALTH PHARMACY - OCONOMOWOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REIMBURSEMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-928-4704
Mailing Address - Street 1:791 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3844
Mailing Address - Country:US
Mailing Address - Phone:262-569-0284
Mailing Address - Fax:262-569-0539
Practice Address - Street 1:791 SUMMIT AVE STE 1106
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3844
Practice Address - Country:US
Practice Address - Phone:262-569-0284
Practice Address - Fax:262-569-0539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI87723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2111058OtherPK