Provider Demographics
NPI:1912905381
Name:KINDRED PHARMACY SERVICES
Entity Type:Organization
Organization Name:KINDRED PHARMACY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:CZEBOTAR
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:262-641-0723
Mailing Address - Street 1:5055 S EMMER DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7361
Mailing Address - Country:US
Mailing Address - Phone:262-641-0723
Mailing Address - Fax:262-641-0619
Practice Address - Street 1:5055 S EMMER DR
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7361
Practice Address - Country:US
Practice Address - Phone:262-641-0723
Practice Address - Fax:262-641-0619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8456042333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33280500Medicaid
WI33280500Medicaid