Provider Demographics
NPI:1568993210
Name:SPRING GREEN PHARMACY INC
Entity Type:Organization
Organization Name:SPRING GREEN PHARMACY INC
Other - Org Name:SPRING GREEN HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER AND VP
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-588-2541
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:SPRING GREEN
Mailing Address - State:WI
Mailing Address - Zip Code:53588-0069
Mailing Address - Country:US
Mailing Address - Phone:608-588-2541
Mailing Address - Fax:608-588-2884
Practice Address - Street 1:208 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SPRING GREEN
Practice Address - State:WI
Practice Address - Zip Code:53588-8002
Practice Address - Country:US
Practice Address - Phone:608-588-2541
Practice Address - Fax:608-588-2884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI6137-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168271OtherPK
WI33122100Medicaid
0271830001Medicare NSC