=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720508245
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE MILLS HOMETOWN PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2017
-----------------------------------------------------
Last Update Date | 06/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 372 E TYRANENA PARK RD
-----------------------------------------------------
City | LAKE MILLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53551-9680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-945-2500
-----------------------------------------------------
Fax | 920-945-2503
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 LOWVILLE RD
-----------------------------------------------------
City | RIO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53960-9437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-992-6800
-----------------------------------------------------
Fax | 920-992-6801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DANIEL STRAUSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-992-6800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 9469-42
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------