Provider Demographics
NPI:1376693614
Name:BLUMON CORPORATION
Entity Type:Organization
Organization Name:BLUMON CORPORATION
Other - Org Name:FORWARD PHARMACY OF CAMBRIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MABIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-347-5420
Mailing Address - Street 1:109 W MAIN ST # 69
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:WI
Mailing Address - Zip Code:53523-9141
Mailing Address - Country:US
Mailing Address - Phone:608-423-3231
Mailing Address - Fax:608-423-7128
Practice Address - Street 1:109 W MAIN ST # 69
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:WI
Practice Address - Zip Code:53523-9141
Practice Address - Country:US
Practice Address - Phone:608-423-3231
Practice Address - Fax:608-423-7128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WI7530-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2114772OtherPK
WI1376693614Medicaid
WI7530-42OtherSTATE LICENSE
WI7530-42OtherSTATE LICENSE