Provider Demographics
NPI:1740392661
Name:SISTER BAY PHARMACY
Entity Type:Organization
Organization Name:SISTER BAY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-854-4121
Mailing Address - Street 1:326 COUNTRY WALK LN
Mailing Address - Street 2:6A
Mailing Address - City:SISTER BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54234-9482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:326 COUNTRY WALK LN
Practice Address - Street 2:6A
Practice Address - City:SISTER BAY
Practice Address - State:WI
Practice Address - Zip Code:54234-9482
Practice Address - Country:US
Practice Address - Phone:920-854-4121
Practice Address - Fax:920-854-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7147042333600000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33178800Medicaid
5120578OtherOTHER ID NUMBER-COMMERCIAL NUMBER