Provider Demographics
NPI:1699225474
Name:GUNDERSEN CLINIC LTD
Entity Type:Organization
Organization Name:GUNDERSEN CLINIC LTD
Other - Org Name:GUNDERSEN LONG TERM CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-775-6369
Mailing Address - Street 1:505 KING ST STE 154
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4062
Mailing Address - Country:US
Mailing Address - Phone:608-782-4448
Mailing Address - Fax:608-782-4449
Practice Address - Street 1:505 KING ST STE 154
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4062
Practice Address - Country:US
Practice Address - Phone:608-782-4448
Practice Address - Fax:608-782-4449
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUNDERSEN CLINIC LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-05
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9420-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100064708Medicaid
2163999OtherPK
WI100064708Medicaid