Healthcare Provider Details

I. General information

NPI: 1619453990
Provider Name (Legal Business Name): ASCENSION WISCONSIN PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S ONEIDA ST
APPLETON WI
54915-1305
US

IV. Provider business mailing address

PO BOX 860644
MINNEAPOLIS MN
55486-0644
US

V. Phone/Fax

Practice location:
  • Phone: 920-831-8467
  • Fax: 920-831-8499
Mailing address:
  • Phone: 414-874-1035
  • Fax: 414-874-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN W SOHN
Title or Position: CFO
Credential:
Phone: 414-465-3090