Provider Demographics
NPI:1679632996
Name:WATERTOWN MEMORIAL HOSPITAL ASSOCIATION INC
Entity Type:Organization
Organization Name:WATERTOWN MEMORIAL HOSPITAL ASSOCIATION INC
Other - Org Name:WATERTOWN MEM HOSPITAL PHY OP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHLOEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-262-4393
Mailing Address - Street 1:125 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3303
Mailing Address - Country:US
Mailing Address - Phone:920-262-4393
Mailing Address - Fax:920-262-4607
Practice Address - Street 1:125 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3303
Practice Address - Country:US
Practice Address - Phone:920-262-4393
Practice Address - Fax:920-262-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54503336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11015400Medicaid
5123928OtherNCPDP PROVIDER IDENTIFICATION NUMBER