MEDICARE: COMMUNITY MEMORIAL HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1407186141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY MEMORIAL HOSPITAL

Provider Business Mailing Address
First Line	:	340 N GREEN BAY AVE
Second Line	:
City	:	GILLETT
State	:	WI
Zip	:	54124-9325
Country	:	US
Telephone Number	:	920-855-2823
Fax Number	:	920-855-6343

Provider Business Practice Location Address
First Line	:	340 N GREEN BAY AVE
Second Line	:
City	:	GILLETT
State	:	WI
Zip	:	54124-9325
Country	:	US
Telephone Number	:	920-855-2823
Fax Number	:	920-855-6343

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	MR. JASON E KNOX
Credential	:
Telephone Number	:	920-846-3444

Provider Enumeration Date	:	12/31/2009
Last Update Date	:	03/07/2023

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Directions to “COMMUNITY MEMORIAL HOSPITAL ” Practice Location

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