Provider Demographics
NPI:1982740544
Name:SKJ INC.
Entity Type:Organization
Organization Name:SKJ INC.
Other - Org Name:DOOR CREEK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-839-3784
Mailing Address - Street 1:431 W COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9385
Mailing Address - Country:US
Mailing Address - Phone:608-839-3784
Mailing Address - Fax:608-839-3786
Practice Address - Street 1:50 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:WI
Practice Address - Zip Code:53531-9353
Practice Address - Country:US
Practice Address - Phone:608-764-8111
Practice Address - Fax:608-764-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8383423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5127813OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI33274500Medicaid
WI33274500Medicaid