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
—
—
3336C0003X
Community/Retail Pharmacy
Primary
9428-42
WI
3336L0003X
Long Term Care Pharmacy
—
—
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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