Provider Demographics
NPI:1750459814
Name:CCOURTLAND PROF. PHARMACY
Entity Type:Organization
Organization Name:CCOURTLAND PROF. PHARMACY
Other - Org Name:THE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-463-8550
Mailing Address - Street 1:8430 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1846
Mailing Address - Country:US
Mailing Address - Phone:414-463-8550
Mailing Address - Fax:414-463-0227
Practice Address - Street 1:8430 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1846
Practice Address - Country:US
Practice Address - Phone:414-463-8550
Practice Address - Fax:414-463-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33144000Medicaid
WI0539880001Medicare ID - Type Unspecified