Provider Demographics
NPI:1457374365
Name:MAYO CLINIC HEALTH SYSTEM-NORTHWEST WISCONSIN REGION, INC.
Entity Type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM-NORTHWEST WISCONSIN REGION, INC.
Other - Org Name:MAYO CLINIC HEALTH SYSTEM PHARMACY-CLAIREMONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:SCHAUS
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-838-5270
Mailing Address - Street 1:PO BOX 083268
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60691-0268
Mailing Address - Country:US
Mailing Address - Phone:715-838-5000
Mailing Address - Fax:
Practice Address - Street 1:733 W CLAIREMONT AVE STE 1
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6101
Practice Address - Country:US
Practice Address - Phone:715-838-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYO CLINIC HEALTH SYSTEM-NORTHWEST WISCONSIN REGION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7260333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
BM3399145OtherDEA
WI33190700Medicaid
51 21253OtherNCPDP
WI0408270004Medicare NSC