Provider Demographics
NPI:1568418929
Name:FROEDTERT HEALTH PHARMACY LLC
Entity Type:Organization
Organization Name:FROEDTERT HEALTH PHARMACY LLC
Other - Org Name:FROEDTERT PHARMACY 375
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIR FH PHARMACY SOLUTIONS
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRIZD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-532-5168
Mailing Address - Street 1:N86W12999 NIGHTINGALE WAY
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051
Mailing Address - Country:US
Mailing Address - Phone:262-532-5173
Mailing Address - Fax:262-532-5105
Practice Address - Street 1:1650 S. 41ST STREET
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220
Practice Address - Country:US
Practice Address - Phone:920-320-4400
Practice Address - Fax:920-320-5104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33216400Medicaid
WI5100704OtherNABP
WI33216400Medicaid