Provider Demographics
NPI:1578587606
Name:KCJE FORD INC
Entity Type:Organization
Organization Name:KCJE FORD INC
Other - Org Name:CASS STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-784-9922
Mailing Address - Street 1:528 CASS ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4507
Mailing Address - Country:US
Mailing Address - Phone:608-784-9922
Mailing Address - Fax:608-784-2212
Practice Address - Street 1:528 CASS ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4507
Practice Address - Country:US
Practice Address - Phone:608-784-9922
Practice Address - Fax:608-784-2212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336C0004X
WI8293-42333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115062OtherPK
WI33165900Medicaid
MN395760800Medicaid
MN395760800Medicaid