=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023459484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRNRX
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2013
-----------------------------------------------------
Last Update Date | 07/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5478 S WESTRIDGE DR SUITE B
-----------------------------------------------------
City | NEW BERLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53151-7948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-784-9600
-----------------------------------------------------
Fax | 262-784-9605
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5478 S WESTRIDGE DR SUITE B
-----------------------------------------------------
City | NEW BERLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53151-7948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-784-9600
-----------------------------------------------------
Fax | 262-784-9605
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | MR. DONALD KOSHAK
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 262-784-9600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 9211-42
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------