Provider Demographics
NPI:1194823138
Name:MEDICAL PHARMACY
Entity Type:Organization
Organization Name:MEDICAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-251-8500
Mailing Address - Street 1:N84W16889 MENOMONEE AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N84W16889 MENOMONEE AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2810
Practice Address - Country:US
Practice Address - Phone:262-251-8500
Practice Address - Fax:262-251-8994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74600423336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5102253OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5102253OtherOTHER ID NUMBER
WI33132000Medicaid
0614720001Medicare NSC