52D2209079 CLIA NUMBER - DEPERE HOMETOWN PHARMACY LLC

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Laboratory Demographics

CLIA Number: 52D2209079

Facility Name: DEPERE HOMETOWN PHARMACY LLC

Facility Address:
510 REDBIRD CIRCLE
DE PERE, WI
ZIP 54115
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Facility Phone Number: 920 992-6800

Facility Type: Pharmacy

Certificate Type: Waiver

NPI Number: 1730749672

Taxonomy: 3336C0003X - Pharmacy
A pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance with federal and state law; counsel patients and caregivers (sometimes independent of the dispensing process); administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes.

CLIA Record

Field Name	Field Value
CLIA Number	52D2209079
LAB Type	Pharmacy
Facility Name	DEPERE HOMETOWN PHARMACY LLC
Street	510 REDBIRD CIRCLE
City	DE PERE
State	WI
ZIP	54115
Phone	920 992-6800
CertificateType	4
CertificateEffectiveDate	1/11/2023
CertificateExpirationDate	1/10/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024