Provider Demographics
NPI:1104532654
Name:BALLWEG FAMILY PHARMACY INC
Entity type:Organization
Organization Name:BALLWEG FAMILY PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BALLWEG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-643-6500
Mailing Address - Street 1:1200 PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-2041
Mailing Address - Country:US
Mailing Address - Phone:608-370-2396
Mailing Address - Fax:
Practice Address - Street 1:1200 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-2041
Practice Address - Country:US
Practice Address - Phone:608-643-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BALLWEG FAMILY PHARMACY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-27
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33282600Medicaid