Provider Demographics
NPI:1508947185
Name:SAUK CITY PHARMACY INC
Entity Type:Organization
Organization Name:SAUK CITY PHARMACY INC
Other - Org Name:SAUK CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BLESSING
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-643-6858
Mailing Address - Street 1:830 WATER ST
Mailing Address - Street 2:
Mailing Address - City:SAUK CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53583
Mailing Address - Country:US
Mailing Address - Phone:608-643-6858
Mailing Address - Fax:608-643-4196
Practice Address - Street 1:830 WATER ST
Practice Address - Street 2:
Practice Address - City:SAUK CITY
Practice Address - State:WI
Practice Address - Zip Code:53583
Practice Address - Country:US
Practice Address - Phone:608-643-6858
Practice Address - Fax:608-643-4196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIG6370423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5115692OtherNCPDP
WI33034300Medicaid
WI33034300Medicaid