Provider Demographics
NPI:1255366225
Name:AURORA PHARMACY INC
Entity type:Organization
Organization Name:AURORA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PANTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-803-3266
Mailing Address - Street 1:2600 KILEY WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-5020
Mailing Address - Country:US
Mailing Address - Phone:920-893-1442
Mailing Address - Fax:920-893-9880
Practice Address - Street 1:2600 KILEY WAY STE 100
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-5020
Practice Address - Country:US
Practice Address - Phone:920-893-1442
Practice Address - Fax:920-893-9880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7685333600000X
3336C0003X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33224300Medicaid
5123776OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI33224300Medicaid
5123776OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WI000086609Medicare PIN