Provider Demographics
NPI:1033657283
Name:MICKLESEN DRUG INC
Entity Type:Organization
Organization Name:MICKLESEN DRUG INC
Other - Org Name:MICKLESEN DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-386-3344
Mailing Address - Street 1:530 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-1799
Mailing Address - Country:US
Mailing Address - Phone:715-386-3344
Mailing Address - Fax:715-386-5198
Practice Address - Street 1:530 2ND ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-1799
Practice Address - Country:US
Practice Address - Phone:715-386-3344
Practice Address - Fax:715-386-5198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WI4862-423336L0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33003000Medicaid
2167180OtherPK
0368230001Medicare PIN