=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497299762
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMACY COMPOUNDING CENTER ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2016
-----------------------------------------------------
Last Update Date | 12/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1907 WEST AVE S
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-6206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-788-4500
-----------------------------------------------------
Fax | 608-788-4501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 185
-----------------------------------------------------
City | WEST SALEM
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54669-0185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-386-9039
-----------------------------------------------------
Fax | 608-788-4501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THOMAS BRIESKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-386-9039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 943642
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------