Provider Demographics
NPI:1790121382
Name:FHHP- KEWASKUM LLC
Entity Type:Organization
Organization Name:FHHP- KEWASKUM LLC
Other - Org Name:FHHP KEWASKUM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOCKS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:920-992-6800
Mailing Address - Street 1:333 LOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RIO
Mailing Address - State:WI
Mailing Address - Zip Code:53960-9437
Mailing Address - Country:US
Mailing Address - Phone:920-992-6800
Mailing Address - Fax:920-992-6801
Practice Address - Street 1:901 FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:KEWASKUM
Practice Address - State:WI
Practice Address - Zip Code:53040-9161
Practice Address - Country:US
Practice Address - Phone:262-477-1700
Practice Address - Fax:262-477-1703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
WI9203-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100031537Medicaid
2140522OtherPK