MEDICARE: SPRING GREEN PHARMACY INC

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	333600000X	Pharmacy
2	3336L0003X	Long Term Care Pharmacy	6137-42	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2168271	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568993210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRING GREEN PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 69
Second Line	:
City	:	SPRING GREEN
State	:	WI
Zip	:	53588-0069
Country	:	US
Telephone Number	:	608-588-2541
Fax Number	:	608-588-2884

Provider Business Practice Location Address
First Line	:	208 E JEFFERSON ST
Second Line	:
City	:	SPRING GREEN
State	:	WI
Zip	:	53588-8002
Country	:	US
Telephone Number	:	608-588-2541
Fax Number	:	608-588-2884

Authorized Official
Title or Position	:	CO OWNER AND VP
Name	:	ALISHA HAHN
Credential	:
Telephone Number	:	608-588-2541

Provider Enumeration Date	:	03/24/2017
Last Update Date	:	03/24/2017

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