Provider Demographics
NPI:1275622953
Name:MORTON DRUG CO INC
Entity Type:Organization
Organization Name:MORTON DRUG CO INC
Other - Org Name:MORTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CORPORATE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-727-8882
Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54957-0778
Mailing Address - Country:US
Mailing Address - Phone:920-727-3853
Mailing Address - Fax:920-727-3867
Practice Address - Street 1:312 RACINE ST
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-2337
Practice Address - Country:US
Practice Address - Phone:920-727-3846
Practice Address - Fax:920-727-3870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WI81293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5107277OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI33177800Medicaid
0195810003Medicare NSC