Provider Demographics
NPI:1801009980
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:A
Authorized Official - Last Name:THEDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-803-3263
Mailing Address - Street 1:2600 KILEY WAY
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073
Mailing Address - Country:US
Mailing Address - Phone:920-449-7090
Mailing Address - Fax:920-449-7091
Practice Address - Street 1:2600 KILEY WAY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073
Practice Address - Country:US
Practice Address - Phone:920-449-7090
Practice Address - Fax:920-449-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8741333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5129932OtherNCPDP
WI33298400Medicaid
WI5129932OtherNCPDP