Provider Demographics
NPI:1104305085
Name:ASCENSION WISCONSIN PHARMACY, INC
Entity type:Organization
Organization Name:ASCENSION WISCONSIN PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-465-3090
Mailing Address - Street 1:PO BOX 860011
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0011
Mailing Address - Country:US
Mailing Address - Phone:414-874-1026
Mailing Address - Fax:414-874-1099
Practice Address - Street 1:2251 N SHORE DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-6710
Practice Address - Country:US
Practice Address - Phone:715-355-9573
Practice Address - Fax:715-355-9579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-10
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9431-42333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33112800Medicaid
WI9431-42OtherWI PHARMACY LICENSE