Healthcare Provider Details

I. General information

NPI: 1659634988
Provider Name (Legal Business Name): HOMETOWN LONG TERM CARE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 09/19/2025
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1571 IVORY DR
SUN PRAIRIE WI
53590-1820
US

IV. Provider business mailing address

333 LOWVILLE RD
RIO WI
53960-9437
US

V. Phone/Fax

Practice location:
  • Phone: 608-846-2750
  • Fax: 608-846-2751
Mailing address:
  • Phone: 920-992-6800
  • Fax: 920-992-6801

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 Number9427-42
License Number StateWI

VIII. Authorized Official

Name: DIANE DEANS
Title or Position: CONTRACTING SPECIALIST
Credential:
Phone: 920-992-6800