Provider Demographics
NPI:1043329824
Name:E.A. MCCULLOUGH, INC.
Entity Type:Organization
Organization Name:E.A. MCCULLOUGH, INC.
Other - Org Name:MCCULLOUGH'S PRESCRIPTIONS AND GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:262-248-6226
Mailing Address - Street 1:694 S WELLS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2106
Mailing Address - Country:US
Mailing Address - Phone:262-248-8582
Mailing Address - Fax:262-248-8593
Practice Address - Street 1:269 BROAD ST
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-1809
Practice Address - Country:US
Practice Address - Phone:262-248-6226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33108300Medicaid
WI0778670001Medicare NSC