=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154321602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENEVOLENT CORPORATION CEDAR COMMUNITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2005
-----------------------------------------------------
Last Update Date | 12/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5595 COUNTY ROAD Z
-----------------------------------------------------
City | WEST BEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53095-9224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-306-2140
-----------------------------------------------------
Fax | 262-306-2141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5595 COUNTY ROAD Z
-----------------------------------------------------
City | WEST BEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53095-9224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-306-2140
-----------------------------------------------------
Fax | 262-306-2141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT OF FINANCE
-----------------------------------------------------
Name | MR. JOSEPH T PICHLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-306-4212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 5115503
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 5115503
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------