Provider Demographics
NPI:1639460736
Name:MERCY HEALTH SYSTEM CORPORATION
Entity Type:Organization
Organization Name:MERCY HEALTH SYSTEM CORPORATION
Other - Org Name:MERCY MALL LTC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF RETAIL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-755-8787
Mailing Address - Street 1:1010 N WASHINGTON ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-1500
Mailing Address - Country:US
Mailing Address - Phone:608-755-4196
Mailing Address - Fax:608-755-8710
Practice Address - Street 1:1010 N WASHINGTON ST STE 107
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-1500
Practice Address - Country:US
Practice Address - Phone:608-755-4196
Practice Address - Fax:608-755-8710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI90683336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639460736Medicaid
5132597OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5132597OtherNCPDP PROVIDER IDENTIFICATION NUMBER