Provider Demographics
NPI:1285625681
Name:ASSISTED LIVING PHARMACY SERVICE, LLC
Entity type:Organization
Organization Name:ASSISTED LIVING PHARMACY SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HUIBREGTSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-433-1700
Mailing Address - Street 1:W133N5138 CAMPBELL DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-7030
Mailing Address - Country:US
Mailing Address - Phone:414-433-1700
Mailing Address - Fax:414-433-1730
Practice Address - Street 1:W133N5138 CAMPBELL DR
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-7030
Practice Address - Country:US
Practice Address - Phone:414-433-1700
Practice Address - Fax:414-433-1730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83730423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33273200Medicaid
5127774OtherNABP
5127774OtherNABP
BA8663329OtherDEA
5127774OtherNABP