Provider Demographics
NPI:1457604928
Name:FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC.
Entity Type:Organization
Organization Name:FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, OUTPATIENT PHARMACY OPERA
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRIZD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:262-532-5168
Mailing Address - Street 1:N86W12999 NIGHTINGALE WAY
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2102
Mailing Address - Country:US
Mailing Address - Phone:262-535-5173
Mailing Address - Fax:262-532-5105
Practice Address - Street 1:W180N8000 TOWN HALL RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-4002
Practice Address - Country:US
Practice Address - Phone:262-532-3066
Practice Address - Fax:262-532-5105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336C0004X, 3336S0011X
WI9162-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137028OtherPK