Provider Demographics
NPI:1568568913
Name:BADGER ACQUISITION OF WISCONSIN, LLC
Entity Type:Organization
Organization Name:BADGER ACQUISITION OF WISCONSIN, LLC
Other - Org Name:LUTHER HAVEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:KUKULSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-719-2600
Mailing Address - Street 1:201 E 4TH ST
Mailing Address - Street 2:900 OMNICARE CENTER
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-4248
Mailing Address - Country:US
Mailing Address - Phone:513-719-2600
Mailing Address - Fax:
Practice Address - Street 1:8949 N 97TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-1695
Practice Address - Country:US
Practice Address - Phone:414-354-8554
Practice Address - Fax:414-354-8521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI032006914332BP3500X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5119145OtherNCPDP
WI33232400Medicaid