1689901084 NPI number — PHILLIPS REEDSBURG PHARMACY INC

Table of content: (NPI 1689901084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689901084 NPI number — PHILLIPS REEDSBURG PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILLIPS REEDSBURG PHARMACY INC
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:
PHILLIPS NEKOOSA PHARMACY
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:
1689901084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 136
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAUSTON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53948-0136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-847-5949
Provider Business Mailing Address Fax Number:
608-847-2670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
232 MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEKOOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54457-1122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-886-3100
Provider Business Practice Location Address Fax Number:
715-886-3105
Provider Enumeration Date:
11/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MACARDY
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
608-847-5949

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  8957-042 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5131812 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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