Healthcare Provider Details

I. General information

NPI: 1942589445
Provider Name (Legal Business Name): SURETY PRO PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2011
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W LAYTON AVE
GREENFIELD WI
53228-3348
US

IV. Provider business mailing address

PO BOX 9830
SALT LAKE CITY UT
84109-9830
US

V. Phone/Fax

Practice location:
  • Phone: 414-433-0188
  • Fax: 414-433-0292
Mailing address:
  • Phone: 877-540-4748
  • Fax: 801-716-4872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number9083-42
License Number StateWI

VIII. Authorized Official

Name: MR. GARY P. OLSZEWSKI
Title or Position: VICE PRESIDENT PHARMACY
Credential: RPH
Phone: 414-433-0188