Provider Demographics
NPI:1679835326
Name:13TH STREET PHARMACY LLC
Entity Type:Organization
Organization Name:13TH STREET PHARMACY LLC
Other - Org Name:13TH STREET PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHTIVELBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-324-9393
Mailing Address - Street 1:1320 W BURNHAM ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3248
Mailing Address - Country:US
Mailing Address - Phone:414-383-4111
Mailing Address - Fax:414-383-2248
Practice Address - Street 1:1320 W BURNHAM ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3248
Practice Address - Country:US
Practice Address - Phone:414-383-4111
Practice Address - Fax:414-383-2248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9131-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100023902Medicaid
2135508OtherPK