Provider Demographics
NPI:1558300632
Name:VERNON MEMORIAL HEALTHCARE INC
Entity Type:Organization
Organization Name:VERNON MEMORIAL HEALTHCARE INC
Other - Org Name:VERNON MEMORIAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-637-4796
Mailing Address - Street 1:407 S MAIN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-2100
Mailing Address - Country:US
Mailing Address - Phone:608-637-4716
Mailing Address - Fax:608-637-4719
Practice Address - Street 1:407 S MAIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-2100
Practice Address - Country:US
Practice Address - Phone:608-637-4718
Practice Address - Fax:608-637-4719
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VERNON MEMORIAL HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-05
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8572-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33289200Medicaid
2110890OtherPK
2110890OtherPK