# 13TH STREET PHARMACY LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** 13th Street Pharmacy LLC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1679835326
- **Authorized official:** RUSSEL SHTIVELBERG (MEMBER)
- **Authorized official phone:** (414) 324-9393

## Contact information

- **Practice address:** 1320 W BURNHAM ST, MILWAUKEE, WI 53204-3248
- **Practice address phone:** (414) 383-4111
- **Practice address fax:** (414) 383-2248
- **Mailing address:** 1320 W BURNHAM ST, MILWAUKEE, WI 53204-3248
- **Mailing address phone:** (414) 383-4111
- **Mailing address fax:** (414) 383-2248

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336C0003X | Community/Retail Pharmacy | 9131-42 | WI | Yes |

## Other

- **Enumeration date:** 06/08/2012
- **Last updated:** 12/03/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100023902 | — | WI |
| 01 | — | 2135508 | PK | — |