Provider Demographics
NPI:1811344666
Name:WAUWATOSA PRESCRIPTION CENTER INC
Entity type:Organization
Organization Name:WAUWATOSA PRESCRIPTION CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO/AO/PIC
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:262-432-7603
Mailing Address - Street 1:1655 W MEQUON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092
Mailing Address - Country:US
Mailing Address - Phone:262-236-7722
Mailing Address - Fax:262-236-7784
Practice Address - Street 1:1655 W MEQUON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092
Practice Address - Country:US
Practice Address - Phone:262-236-7722
Practice Address - Fax:262-236-7784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-23
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9271-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160228OtherPK
WI100038951Medicaid