Provider Demographics
NPI:1659634988
Name:HOMETOWN LONG TERM CARE PHARMACY LLC
Entity Type:Organization
Organization Name:HOMETOWN LONG TERM CARE PHARMACY LLC
Other - Org Name:HOMETOWN LONG TERM CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-992-6800
Mailing Address - Street 1:333 LOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RIO
Mailing Address - State:WI
Mailing Address - Zip Code:53960-9437
Mailing Address - Country:US
Mailing Address - Phone:920-992-6800
Mailing Address - Fax:920-992-6801
Practice Address - Street 1:1571 IVORY DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1820
Practice Address - Country:US
Practice Address - Phone:608-846-2750
Practice Address - Fax:608-846-2751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9427-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137457OtherPK