Provider Demographics
NPI:1619071628
Name:MORELAND PLAZA PHARMACY, INC
Entity Type:Organization
Organization Name:MORELAND PLAZA PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOFF
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:262-542-4488
Mailing Address - Street 1:827 W MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2963
Mailing Address - Country:US
Mailing Address - Phone:262-542-4488
Mailing Address - Fax:262-650-4040
Practice Address - Street 1:827 W MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2963
Practice Address - Country:US
Practice Address - Phone:262-542-4488
Practice Address - Fax:262-650-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4015-0423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33195300Medicaid
0680620002Medicare NSC