Healthcare Provider Details

I. General information

NPI: 1316277056
Provider Name (Legal Business Name): COMMUNITY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 03/07/2023
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 MAIN ST
SURING WI
54174-9012
US

IV. Provider business mailing address

913 MAIN ST
SURING WI
54174-9012
US

V. Phone/Fax

Practice location:
  • Phone: 920-842-1147
  • Fax: 920-842-1160
Mailing address:
  • Phone: 920-842-1147
  • Fax: 920-842-1160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON E KNOX
Title or Position: PHARMACY MANAGER
Credential:
Phone: 920-846-3444