Provider Demographics
NPI:1821584343
Name:MORELAND PLAZA PHARMACY, INC
Entity Type:Organization
Organization Name:MORELAND PLAZA PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-542-4488
Mailing Address - Street 1:827 W MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2963
Mailing Address - Country:US
Mailing Address - Phone:262-542-4488
Mailing Address - Fax:262-650-4040
Practice Address - Street 1:827 W MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2963
Practice Address - Country:US
Practice Address - Phone:262-542-4488
Practice Address - Fax:262-650-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
4015-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33195300Medicaid