MEDICARE: 13TH STREET PHARMACY 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	9131-42	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2135508	OTHER		PK

General Provider Information

NPI Number	:	1679835326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	13TH STREET PHARMACY LLC

Provider Business Mailing Address
First Line	:	1320 W BURNHAM ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-3248
Country	:	US
Telephone Number	:	414-383-4111
Fax Number	:	414-383-2248

Provider Business Practice Location Address
First Line	:	1320 W BURNHAM ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-3248
Country	:	US
Telephone Number	:	414-383-4111
Fax Number	:	414-383-2248

Authorized Official
Title or Position	:	MEMBER
Name	:	RUSSEL SHTIVELBERG
Credential	:
Telephone Number	:	414-324-9393

Provider Enumeration Date	:	06/08/2012
Last Update Date	:	12/03/2014

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