Basic Information
Provider Information | |||||||||
NPI: | 1972725240 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HO CHUNK NATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOUSE OF WELLNESS PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | S2845 WHITE EAGLE RD | ||||||||
Address2: |   | ||||||||
City: | BARABOO | ||||||||
State: | WI | ||||||||
PostalCode: | 539139064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083551240 | ||||||||
FaxNumber: | 6083561233 | ||||||||
Practice Location | |||||||||
Address1: | S2845 WHITE EAGLE RD | ||||||||
Address2: |   | ||||||||
City: | BARABOO | ||||||||
State: | WI | ||||||||
PostalCode: | 539139064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083555177 | ||||||||
FaxNumber: | 6083561233 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2007 | ||||||||
LastUpdateDate: | 07/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOORE | ||||||||
AuthorizedOfficialFirstName: | ABIGAIL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING PHARMACIST | ||||||||
AuthorizedOfficialTelephone: | 6083551240 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHARMD | ||||||||
NPICertificationDate: | 07/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X |   |   | N |   | Suppliers | Pharmacy | Clinic Pharmacy | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 332800000X | 8332-42 | WI | Y |   | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 2109072 | 01 |   | PK | OTHER | 33246800 | 05 | WI |   | MEDICAID |