Provider Demographics
NPI:1720003452
Name:AURORA PHARMACY INC
Entity Type:Organization
Organization Name:AURORA PHARMACY INC
Other - Org Name:AURORA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:THEDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-803-3263
Mailing Address - Street 1:1138 MILLER PARK WAY
Mailing Address - Street 2:
Mailing Address - City:WEST MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1138 MILLER PARK WAY
Practice Address - Street 2:
Practice Address - City:WEST MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3653
Practice Address - Country:US
Practice Address - Phone:414-389-1196
Practice Address - Fax:414-389-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8303333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33268400Medicaid
5127370OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI33268400Medicaid