Provider Demographics
NPI:1811416639
Name:COMMUNITY MEMORIAL HOSPITAL OF MENOMONEE FALLS INC
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL OF MENOMONEE FALLS INC
Other - Org Name:F & MCW DREXEL TOWN SQUARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERHACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-532-5163
Mailing Address - Street 1:N86W12999 NIGHTINGALE WAY
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2102
Mailing Address - Country:US
Mailing Address - Phone:262-532-5163
Mailing Address - Fax:
Practice Address - Street 1:7901 S 6TH ST
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-2010
Practice Address - Country:US
Practice Address - Phone:414-346-8050
Practice Address - Fax:262-532-5105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9462-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1811416639Medicaid
2171439OtherPK