Provider Demographics
NPI:1679801807
Name:KCJE FORD INC
Entity type:Organization
Organization Name:KCJE FORD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BASSEUNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-784-9922
Mailing Address - Street 1:PO BOX 2496
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54602-2496
Mailing Address - Country:US
Mailing Address - Phone:608-782-4448
Mailing Address - Fax:608-782-4449
Practice Address - Street 1:505 KING ST STE 154
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4062
Practice Address - Country:US
Practice Address - Phone:608-782-4448
Practice Address - Fax:608-782-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-30
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9122-042333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100007292Medicaid
2122806OtherPK