Provider Demographics
NPI:1821081936
Name:MAPLEWOOD OF SAUK PRAIRIE
Entity Type:Organization
Organization Name:MAPLEWOOD OF SAUK PRAIRIE
Other - Org Name:MAPLEWOOD OF SAUK PRAIRIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-644-9265
Mailing Address - Street 1:245 SYCAMORE STEET
Mailing Address - Street 2:
Mailing Address - City:SAUK CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53583
Mailing Address - Country:US
Mailing Address - Phone:608-644-9265
Mailing Address - Fax:608-643-2629
Practice Address - Street 1:245 SYCAMORE STEET
Practice Address - Street 2:
Practice Address - City:SAUK CITY
Practice Address - State:WI
Practice Address - Zip Code:53583
Practice Address - Country:US
Practice Address - Phone:608-644-9265
Practice Address - Fax:608-643-2629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33204100Medicaid
2113946OtherPK