Provider Demographics
NPI:1063781920
Name:O CONNELL PHARMACY LTD
Entity type:Organization
Organization Name:O CONNELL PHARMACY LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-837-5949
Mailing Address - Street 1:302 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-9827
Mailing Address - Country:US
Mailing Address - Phone:608-837-8002
Mailing Address - Fax:608-478-3900
Practice Address - Street 1:125 S THOMPSON RD
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-2526
Practice Address - Country:US
Practice Address - Phone:608-837-8002
Practice Address - Fax:608-478-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9103-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133222OtherPK
5132965OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI100022739Medicaid