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Organization
PROVIDENCE FAMILY PHARMACY LLC
Active
Organization
PROVIDENCE FAMILY PHARMACY LLC
Active
Other names
PROVIDENCE FAMILY PHARMACY LLC
Organization subpart
No
Provider details
NPI number
Authorized official
ABIOLA OKUSANYA (MANAGER)
(414) 885-0550
Entity
Organization
Contact information
Practice address
2500 W SILVER SPRING DR, GLENDALE, WI 53209-4218
(414) 885-0550
(414) 885-0552
Mailing address
2500 W SILVER SPRING DR, GLENDALE, WI 53209-4218
(414) 885-0550
(414) 885-0552
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
NULL
3336C0003X
Community/Retail Pharmacy
Primary
9428-42
WI
3336L0003X
Long Term Care Pharmacy
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2163951
PK
—
Enumeration date
08/31/2016
Last updated
02/20/2020
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