MEDICARE: CCOURTLAND PROF. PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	7480	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750459814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCOURTLAND PROF. PHARMACY

Provider Business Mailing Address
First Line	:	8430 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-1846
Country	:	US
Telephone Number	:	414-463-8550
Fax Number	:	414-463-0227

Provider Business Practice Location Address
First Line	:	8430 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-1846
Country	:	US
Telephone Number	:	414-463-8550
Fax Number	:	414-463-0227

Authorized Official
Title or Position	:	OWNER
Name	:	JAMES GOLLIN
Credential	:
Telephone Number	:	414-463-8550

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	08/22/2020

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