Provider Demographics
NPI:1497299762
Name:PHARMACY COMPOUNDING CENTER ASSOCIATES LLC
Entity type:Organization
Organization Name:PHARMACY COMPOUNDING CENTER ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIESKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-386-9039
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-0185
Mailing Address - Country:US
Mailing Address - Phone:608-386-9039
Mailing Address - Fax:608-788-4501
Practice Address - Street 1:1907 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6206
Practice Address - Country:US
Practice Address - Phone:608-788-4500
Practice Address - Fax:608-788-4501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9436423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI943642OtherWISCONSIN PHARMACY LIC