Healthcare Provider Details

I. General information

NPI: 1164974036
Provider Name (Legal Business Name): CORCORAN HEALTHCARE ENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E 2ND ST
RICHLAND CENTER WI
53581-1900
US

IV. Provider business mailing address

301 E 2ND ST PO BOX 309
RICHLAND CENTER WI
53581-1900
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-8806
  • Fax: 608-647-2029
Mailing address:
  • Phone: 608-647-8806
  • Fax: 608-647-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number7973-042
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number7973-042
License Number StateWI

VIII. Authorized Official

Name: PAUL F CORCORAN
Title or Position: OWNER
Credential: RPH
Phone: 608-647-8806