Provider Demographics
NPI:1184784159
Name:THEDACARE MEDICAL CENTER-BERLIN INC
Entity type:Organization
Organization Name:THEDACARE MEDICAL CENTER-BERLIN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OF RECORD
Authorized Official - Prefix:
Authorized Official - First Name:ALISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:920-787-5757
Mailing Address - Street 1:N2934 HWY 22 N
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982
Mailing Address - Country:US
Mailing Address - Phone:920-787-5757
Mailing Address - Fax:920-787-5382
Practice Address - Street 1:N2934 HWY 22 N
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-5267
Practice Address - Country:US
Practice Address - Phone:920-787-5757
Practice Address - Fax:920-787-5382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI7733-423336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33230600Medicaid
2108771OtherPK
2108771OtherPK