Basic Information
| Provider Information | |||||||||
| NPI: | 1932772605 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAUKESHA HEALTH SYSTEMS, INC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROHEALTH PHARMACY-MUKWONAGO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | N17 W24100 RIVERWOOD DR. | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531881187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629281000 | ||||||||
| FaxNumber: | 2629538829 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 MAPLE AVE. | ||||||||
| Address2: | |||||||||
| City: | MUKWONAGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531498475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625217410 | ||||||||
| FaxNumber: | 2629538829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2021 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2629284704 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAUKESHA HEALTH SYSTEM, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.