Provider Demographics
NPI:1124033758
Name:MARSHLAND PHARMACIES INC
Entity Type:Organization
Organization Name:MARSHLAND PHARMACIES INC
Other - Org Name:MARSHLAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER/PHARM MGR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-356-0040
Mailing Address - Street 1:705 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3053
Mailing Address - Country:US
Mailing Address - Phone:920-356-0040
Mailing Address - Fax:920-356-0056
Practice Address - Street 1:705 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3053
Practice Address - Country:US
Practice Address - Phone:920-356-0040
Practice Address - Fax:920-356-0056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WI85460423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2110854OtherPK
WI33287900Medicaid
0136480003Medicare NSC