Provider Demographics
NPI:1659362101
Name:ASCENSION WISCONSIN PHARMACY, INC
Entity Type:Organization
Organization Name:ASCENSION WISCONSIN PHARMACY, INC
Other - Org Name:ASCENSION RX 1112
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 1:5000 W CHAMBERS ST RM 5223
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1650
Mailing Address - Country:US
Mailing Address - Phone:414-874-1035
Mailing Address - Fax:414-874-1099
Practice Address - Street 1:2301 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4508
Practice Address - Country:US
Practice Address - Phone:414-585-1303
Practice Address - Fax:414-585-2809
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASCENSION WISCONSIN PHARMACY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-03
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33219300Medicaid
WI33219300Medicaid