Healthcare Provider Details

I. General information

NPI: 1356722045
Provider Name (Legal Business Name): FROEDTERT MEMORIAL LUTHERAN HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE CFAC PHARMACY
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

N86W12999 NIGHTINGALE WAY
MENOMONEE FALLS WI
53051-2102
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-1295
  • Fax: 414-805-1299
Mailing address:
  • Phone: 262-532-5173
  • Fax: 262-532-5105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number9309-42
License Number StateWI

VIII. Authorized Official

Name: KEVIN PERHACH
Title or Position: BUSINESS MANAGER
Credential:
Phone: 414-805-6531