Provider Demographics
NPI:1972695278
Name:UNIVERSITY OF WISCONSIN HOSPITALS AND CLINICS AUTHORITY
Entity Type:Organization
Organization Name:UNIVERSITY OF WISCONSIN HOSPITALS AND CLINICS AUTHORITY
Other - Org Name:NORTHEAST FAMILY PRACTICE PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-263-7013
Mailing Address - Street 1:600 HIGHLAND AVE
Mailing Address - Street 2:PHARMACY F6/133
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-1530
Mailing Address - Country:US
Mailing Address - Phone:608-263-1290
Mailing Address - Fax:608-263-9424
Practice Address - Street 1:3209 DRYDEN DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3015
Practice Address - Country:US
Practice Address - Phone:608-241-9638
Practice Address - Fax:608-241-0857
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF WISCONSIN HOSPITALS AND CLINICS AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8035333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5121443OtherNCPDP NO
WI33212000Medicaid
WI8035OtherPHARMACY LICENSE NO
0641600006OtherPTAN (PHARMACY MEDICARE PROVIDER NUMBER)
0641600006OtherPTAN (PHARMACY MEDICARE PROVIDER NUMBER)
WI8035OtherPHARMACY LICENSE NO