Healthcare Provider Details

I. General information

NPI: 1619926854
Provider Name (Legal Business Name): TARGET PHARMACY T-1060
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 JUNCTION RD
MADISON WI
53717-2615
US

IV. Provider business mailing address

201 JUNCTION RD
MADISON WI
53717-2615
US

V. Phone/Fax

Practice location:
  • Phone: 608-827-9483
  • Fax: 608-827-9483
Mailing address:
  • Phone: 608-827-9483
  • Fax: 608-827-9483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number8075
License Number StateWI

VIII. Authorized Official

Name: CHARLIE LEE
Title or Position: PHARMACY TEAM LEADER
Credential: RPH
Phone: 608-827-9483