MEDICARE: PHARMACY COMPOUNDING CENTER ASSOCIATES LLC

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	3336C0003X	Community/Retail Pharmacy	943642	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	943642	OTHER	WI	WISCONSIN PHARMACY LIC

General Provider Information

NPI Number	:	1497299762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHARMACY COMPOUNDING CENTER ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	PO BOX 185
Second Line	:
City	:	WEST SALEM
State	:	WI
Zip	:	54669-0185
Country	:	US
Telephone Number	:	608-386-9039
Fax Number	:	608-788-4501

Provider Business Practice Location Address
First Line	:	1907 WEST AVE S
Second Line	:
City	:	LA CROSSE
State	:	WI
Zip	:	54601-6206
Country	:	US
Telephone Number	:	608-788-4500
Fax Number	:	608-788-4501

Authorized Official
Title or Position	:	OWNER
Name	:	THOMAS BRIESKE
Credential	:
Telephone Number	:	608-386-9039

Provider Enumeration Date	:	12/06/2016
Last Update Date	:	12/06/2016

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