Provider Demographics
NPI:1871059626
Name:MONROE HOMETOWN PHARMACY WEST LLC
Entity type:Organization
Organization Name:MONROE HOMETOWN PHARMACY WEST LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-992-6800
Mailing Address - Street 1:333 LOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RIO
Mailing Address - State:WI
Mailing Address - Zip Code:53960-9437
Mailing Address - Country:US
Mailing Address - Phone:920-992-6800
Mailing Address - Fax:
Practice Address - Street 1:418 W 10 1/2 ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1378
Practice Address - Country:US
Practice Address - Phone:608-426-6540
Practice Address - Fax:608-426-6561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-18
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100086153Medicaid