1376693614 NPI number — BLUMON CORPORATION

Table of content: (NPI 1376693614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376693614 NPI number — BLUMON CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUMON CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FORWARD PHARMACY OF CAMBRIDGE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376693614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 W MAIN ST # 69
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53523-9141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-423-3231
Provider Business Mailing Address Fax Number:
608-423-7128

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 W MAIN ST # 69
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53523-9141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-423-3231
Provider Business Practice Location Address Fax Number:
608-423-7128
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MABIE
Authorized Official First Name:
MATT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
608-347-5420

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 7530-42 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2114772 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1376693614 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7530-42 . This is a "STATE LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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