Provider Demographics
NPI:1992704159
Name:HEALTH CENTER PHARMACY OF MENOMONEE FALLS
Entity type:Organization
Organization Name:HEALTH CENTER PHARMACY OF MENOMONEE FALLS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFBAUER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:262-574-7869
Mailing Address - Street 1:N14W23900 STONE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1135
Mailing Address - Country:US
Mailing Address - Phone:262-574-7869
Mailing Address - Fax:262-574-8019
Practice Address - Street 1:N14W23900 STONE RIDGE DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1135
Practice Address - Country:US
Practice Address - Phone:262-574-7869
Practice Address - Fax:262-574-8019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
WI67340423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33196600Medicaid
5118105OtherNCPDP PROVIDER IDENTIFICATION NUMBER