Provider Demographics
NPI:1750527792
Name:ROCKMED LLC
Entity type:Organization
Organization Name:ROCKMED LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-884-6644
Mailing Address - Street 1:711 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-1530
Mailing Address - Country:US
Mailing Address - Phone:608-884-6644
Mailing Address - Fax:855-523-0916
Practice Address - Street 1:711 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-1530
Practice Address - Country:US
Practice Address - Phone:608-884-6644
Practice Address - Fax:855-523-0916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9178-0423336L0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118330OtherPK
WIK300100832OtherPTAN
WI1750527792Medicaid