# THEDACARE MEDICAL CENTER-BERLIN INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** ThedaCare Pharmacy - Wautoma
- **Organization subpart:** No

## Provider details

- **NPI number:** 1184784159
- **Authorized official:** ALISSA GIES PHARM D (PHARMACIST OF RECORD)
- **Authorized official phone:** (920) 787-5757

## Contact information

- **Practice address:** N2934 HWY 22 N, WAUTOMA, WI 54982-5267
- **Practice address phone:** (920) 787-5757
- **Practice address fax:** (920) 787-5382
- **Mailing address:** N2934 HWY 22 N, WAUTOMA, WI 54982
- **Mailing address phone:** (920) 787-5757
- **Mailing address fax:** (920) 787-5382

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 7733-42 | WI | Yes |

## Other

- **Enumeration date:** 12/11/2006
- **Last updated:** 04/18/2017

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2108771 | PK | — |
| 05 | — | 33230600 | — | WI |