Provider Demographics
NPI:1134272156
Name:WILKE'S VILLAGE PHARMACY
Entity type:Organization
Organization Name:WILKE'S VILLAGE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:WILKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-442-4400
Mailing Address - Street 1:9000 W BURLEIGH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3632
Mailing Address - Country:US
Mailing Address - Phone:414-442-4400
Mailing Address - Fax:414-442-1385
Practice Address - Street 1:9000 W BURLEIGH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-3632
Practice Address - Country:US
Practice Address - Phone:414-442-4400
Practice Address - Fax:414-442-1385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9832-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========Medicaid