=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821081936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAPLEWOOD OF SAUK PRAIRIE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2005
-----------------------------------------------------
Last Update Date | 10/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 SYCAMORE STEET
-----------------------------------------------------
City | SAUK CITY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-644-9265
-----------------------------------------------------
Fax | 608-643-2629
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 SYCAMORE STEET
-----------------------------------------------------
City | SAUK CITY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-644-9265
-----------------------------------------------------
Fax | 608-643-2629
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF PHARMACIST
-----------------------------------------------------
Name | MR. RICHARD CARL HARRIS
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 608-644-9265
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------