Basic Information
| Provider Information | |||||||||
| NPI: | 1194889980 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRUS WAUSAU HOSPITAL OUTPATIENT PHARMACY | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 333 PINE RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472871 | ||||||||
| FaxNumber: | 7158472551 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 PINE RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472871 | ||||||||
| FaxNumber: | 7158472551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BJORK | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 7158472871 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 7878-042 | WI | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0361120002 | 05 | WI | MEDICAID |