Provider Demographics
NPI:1710916416
Name:BALLWEG FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:BALLWEG FAMILY PHARMACY INC
Other - Org Name:BALLWEG FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLWEG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-643-6500
Mailing Address - Street 1:1200 PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-2041
Mailing Address - Country:US
Mailing Address - Phone:608-643-6500
Mailing Address - Fax:
Practice Address - Street 1:1200 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-2041
Practice Address - Country:US
Practice Address - Phone:608-643-6500
Practice Address - Fax:608-643-6533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8489-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2110297OtherPK