Provider Demographics
NPI:1558307942
Name:MERCY HEALTH SYSTEM CORPORATION
Entity Type:Organization
Organization Name:MERCY HEALTH SYSTEM CORPORATION
Other - Org Name:MERCY MALL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:JANCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:608-756-6664
Mailing Address - Street 1:1010 N WASHINGTON ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-1561
Mailing Address - Country:US
Mailing Address - Phone:608-754-0286
Mailing Address - Fax:
Practice Address - Street 1:1010 N WASHINGTON ST
Practice Address - Street 2:SUITE 105
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-1561
Practice Address - Country:US
Practice Address - Phone:608-754-0286
Practice Address - Fax:608-754-0027
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-22
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7720333600000X, 3336M0002X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33227700Medicaid
5101263OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI33227700Medicaid