Healthcare Provider Details

I. General information

NPI: 1588036826
Provider Name (Legal Business Name): BEAVER DAM HOMETOWN PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 N SPRING ST
BEAVER DAM WI
53916-2040
US

IV. Provider business mailing address

333 LOWVILLE RD
RIO WI
53960-9437
US

V. Phone/Fax

Practice location:
  • Phone: 920-356-1500
  • Fax: 920-356-1510
Mailing address:
  • Phone: 920-992-6800
  • Fax: 920-614-6100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number9411-42
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DANIEL STRAUSE
Title or Position: OWNER
Credential:
Phone: 920-992-6800