Provider Demographics
NPI:1619969490
Name:VERNON MEMORIAL HEALTHCARE, INC.
Entity Type:Organization
Organization Name:VERNON MEMORIAL HEALTHCARE, INC.
Other - Org Name:SOLAR TOWN PHARMACY - VHM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-637-4796
Mailing Address - Street 1:407 S MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-4004
Mailing Address - Country:US
Mailing Address - Phone:608-624-3344
Mailing Address - Fax:608-624-3944
Practice Address - Street 1:104 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:SOLDIERS GROVE
Practice Address - State:WI
Practice Address - Zip Code:54655-7523
Practice Address - Country:US
Practice Address - Phone:608-624-3344
Practice Address - Fax:608-624-3944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VERNON MEMORIAL HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8490-042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9047-042OtherSTATE PHARMACY LICENSE
WIBS9360924OtherDEA NUMBER
WI5493530001Medicare NSC