Provider Demographics
NPI:1528194933
Name:SPARTA PHARMACY LLC.
Entity Type:Organization
Organization Name:SPARTA PHARMACY LLC.
Other - Org Name:SPARTA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIESKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-386-9039
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-0185
Mailing Address - Country:US
Mailing Address - Phone:608-269-2949
Mailing Address - Fax:608-269-3330
Practice Address - Street 1:201 S WATER ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1724
Practice Address - Country:US
Practice Address - Phone:608-269-2949
Practice Address - Fax:608-269-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WI87830423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2111020OtherPK
WI33296600Medicaid
2111020OtherPK