Provider Demographics
NPI:1699793380
Name:COMMUNITY PHARMACY CO-OPERATIVE
Entity type:Organization
Organization Name:COMMUNITY PHARMACY CO-OPERATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPEERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:608-251-4454
Mailing Address - Street 1:130 FAIROAKS AVE.
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704
Mailing Address - Country:US
Mailing Address - Phone:608-251-4454
Mailing Address - Fax:608-251-3853
Practice Address - Street 1:130 FAIROAKS AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704
Practice Address - Country:US
Practice Address - Phone:608-251-4454
Practice Address - Fax:608-251-3853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI64643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1699793380Medicaid
480001188OtherMEDCO PAID
WI33134900Medicaid