Provider Demographics
NPI:1821022047
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 SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PANTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-803-3266
Mailing Address - Street 1:6969 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE B120
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6969 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE B120
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3962
Practice Address - Country:US
Practice Address - Phone:414-540-1194
Practice Address - Fax:414-540-1497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8459333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5128308OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI33280700Medicaid
WI000086609Medicare PIN
5128308OtherOTHER ID NUMBER-COMMERCIAL NUMBER