Provider Demographics
NPI:1407265598
Name:MODERN APOTHECARY, LLC
Entity Type:Organization
Organization Name:MODERN APOTHECARY, LLC
Other - Org Name:MODERN APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MERRITT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:262-997-9573
Mailing Address - Street 1:5700 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-4104
Mailing Address - Country:US
Mailing Address - Phone:262-997-9573
Mailing Address - Fax:262-997-9574
Practice Address - Street 1:5700 6TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4104
Practice Address - Country:US
Practice Address - Phone:262-997-9573
Practice Address - Fax:262-997-9574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9274-42333600000X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5134476OtherNCPDP NUMBER
5134476OtherNCPDP NUMBER