Healthcare Provider Details

I. General information

NPI: 1083935233
Provider Name (Legal Business Name): JAT PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 10/06/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 BURTON BOULEVARD SUITE A
DEFOREST WI
53532
US

IV. Provider business mailing address

805 BURTON BOULEVARD SUITE A
DEFOREST WI
53532
US

V. Phone/Fax

Practice location:
  • Phone: 877-490-3577
  • Fax: 877-490-3576
Mailing address:
  • Phone: 877-490-3577
  • Fax: 877-490-3576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number9015-42
License Number StateWI

VIII. Authorized Official

Name: WILLIAM A. BARTKOWIAK
Title or Position: DIRECTOR OF PHARMACY/PHARMACIST IN
Credential: R.PH., MBA
Phone: 877-490-3577