Provider Demographics
NPI:1487997235
Name:IV COMPOUND CENTER OF WISCONSIN LLC
Entity type:Organization
Organization Name:IV COMPOUND CENTER OF WISCONSIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KOSHAK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:262-641-2850
Mailing Address - Street 1:5478 S WESTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7948
Mailing Address - Country:US
Mailing Address - Phone:262-641-2850
Mailing Address - Fax:262-641-2854
Practice Address - Street 1:5478 S WESTRIDGE DR
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7948
Practice Address - Country:US
Practice Address - Phone:262-641-2850
Practice Address - Fax:262-641-2854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-30
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8543-0423336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy