Provider Demographics
NPI:1013169598
Name:FORUM EXTENDED CARE SERVICES OF WISCONSIN INC
Entity Type:Organization
Organization Name:FORUM EXTENDED CARE SERVICES OF WISCONSIN INC
Other - Org Name:WILLOW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-673-8727
Mailing Address - Street 1:4201 W VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6700
Mailing Address - Country:US
Mailing Address - Phone:847-673-8727
Mailing Address - Fax:847-673-6215
Practice Address - Street 1:2445 DARWIN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3116
Practice Address - Country:US
Practice Address - Phone:608-240-2280
Practice Address - Fax:608-240-2288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9417-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100001648Medicaid
2117872OtherPK
2117872OtherPK