Provider Demographics
NPI:1962564583
Name:HAYWARD PHARMACY INC.
Entity type:Organization
Organization Name:HAYWARD PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:414-640-7129
Mailing Address - Street 1:9130 W. NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2696
Mailing Address - Country:US
Mailing Address - Phone:414-258-9550
Mailing Address - Fax:414-258-1088
Practice Address - Street 1:9130 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2623
Practice Address - Country:US
Practice Address - Phone:414-258-9550
Practice Address - Fax:414-258-1088
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAYWARD PHARMACY INC DBA SWAN SERV U PHARM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-14
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53433336C0003X
333600000X
WI5343-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33139800Medicaid
5103205OtherOTHER ID NUMBER
WI33139800Medicaid