Provider Demographics
NPI:1508910548
Name:AURORA PHARMACY, INC.
Entity Type:Organization
Organization Name:AURORA PHARMACY, INC.
Other - Org Name:AURORA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:THEDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-803-3263
Mailing Address - Street 1:4310 67TH DR
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-9338
Mailing Address - Country:US
Mailing Address - Phone:262-878-1171
Mailing Address - Fax:262-878-2406
Practice Address - Street 1:4310 67TH DR
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-9338
Practice Address - Country:US
Practice Address - Phone:262-878-1171
Practice Address - Fax:262-878-2406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8716333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5129742OtherNCPDP
WI33295800Medicaid
WI000086609Medicare PIN
WI0532850184Medicare NSC