Provider Demographics
NPI:1710225693
Name:ST CLARE MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:ST CLARE MEMORIAL HOSPITAL INC
Other - Org Name:HSHS ST. CLARE MEMORIAL HOSPITAL PHARMACY GILLETT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-884-5660
Mailing Address - Street 1:117 N MCKENZIE ST
Mailing Address - Street 2:PO BOX 558
Mailing Address - City:GILLETT
Mailing Address - State:WI
Mailing Address - Zip Code:54124-9142
Mailing Address - Country:US
Mailing Address - Phone:920-848-6323
Mailing Address - Fax:920-848-8502
Practice Address - Street 1:117 N MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:GILLETT
Practice Address - State:WI
Practice Address - Zip Code:54124-9142
Practice Address - Country:US
Practice Address - Phone:920-848-6323
Practice Address - Fax:920-848-8502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-28
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9179-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1000027937Medicaid
2138350OtherPK