Provider Demographics
NPI:1639237019
Name:AURORA PHARMACY, INC.
Entity Type:Organization
Organization Name:AURORA PHARMACY, INC.
Other - Org Name:AURORA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:THEDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-803-3263
Mailing Address - Street 1:470 GRAND VIEW AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010
Mailing Address - Country:US
Mailing Address - Phone:920-533-3970
Mailing Address - Fax:920-533-3971
Practice Address - Street 1:470 GRAND VIEW AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:CAMPBELLSPORT
Practice Address - State:WI
Practice Address - Zip Code:53010
Practice Address - Country:US
Practice Address - Phone:920-533-3970
Practice Address - Fax:920-533-3971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86973336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33294100Medicaid
WI5129615OtherNCPDP
WI5129615OtherNCPDP