Provider Demographics
NPI:1619453990
Name:ASCENSION WISCONSIN PHARMACY, INC
Entity Type:Organization
Organization Name:ASCENSION WISCONSIN PHARMACY, INC
Other - Org Name:ASCENSION RX 1111
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-465-3090
Mailing Address - Street 1:PO BOX 860644
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0644
Mailing Address - Country:US
Mailing Address - Phone:414-874-1035
Mailing Address - Fax:414-874-1099
Practice Address - Street 1:1506 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1305
Practice Address - Country:US
Practice Address - Phone:920-831-8467
Practice Address - Fax:920-831-8499
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASCENSION WISCONSIN PHARMACY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-19
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
WI9431-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy