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General NPI Number Information
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NPI Number | 1982797312
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Entity Type | Organization
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Legal Business Name | PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL, INC.
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Dates
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Enumeration Date | 09/30/2006
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Last Update Date | 12/14/2022
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Provider Practice Location Address
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Address Line | 791 SUMMIT AVE
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City | OCONOMOWOC
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State | WI
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Zip | 53066-3844
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Country | US
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Telephone | 262-569-0471
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Fax | 262-569-0422
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Provider Business Mailing Address
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Address Line | 791 SUMMIT AVE
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City | OCONOMOWOC
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State | WI
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Zip | 53066-3844
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Country | US
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Telephone | 262-569-0471
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Fax | 262-569-0422
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Authorized Official
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Title or Position | REIMBURSEMENT MANAGER
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Name | THOMAS W JOHNSON
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Credential | RPH
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Telephone | 262-928-4704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336I0012X
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Taxonomy Name | Institutional Pharmacy
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License Number | 4758042
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License Number State | WI
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