=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790071637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST MARY'S HOSPITAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2011
-----------------------------------------------------
Last Update Date | 06/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2840 OKEEFFE AVE
-----------------------------------------------------
City | SUN PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53590-7077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-229-8484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6501 CITY WEST PKWY
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55344-3248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-653-2525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PHARMACY
-----------------------------------------------------
Name | BOB FALSEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-653-2525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------