Provider Demographics
NPI:1942589445
Name:SURETY PRO PHARMACY LLC
Entity Type:Organization
Organization Name:SURETY PRO PHARMACY LLC
Other - Org Name:SURETY PRO PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:OLSZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:414-433-0188
Mailing Address - Street 1:PO BOX 9830
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9830
Mailing Address - Country:US
Mailing Address - Phone:877-540-4748
Mailing Address - Fax:801-716-4872
Practice Address - Street 1:9200 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3348
Practice Address - Country:US
Practice Address - Phone:414-433-0188
Practice Address - Fax:414-433-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9083-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131230OtherPK
WI6786310001Medicare NSC