Provider Demographics
NPI:1417999897
Name:MD GROUP LLC
Entity Type:Organization
Organization Name:MD GROUP LLC
Other - Org Name:DEFOREST HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MABIE
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:920-992-6800
Mailing Address - Street 1:333 LOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RIO
Mailing Address - State:WI
Mailing Address - Zip Code:53960-9437
Mailing Address - Country:US
Mailing Address - Phone:920-992-6800
Mailing Address - Fax:920-992-6801
Practice Address - Street 1:645 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DE FOREST
Practice Address - State:WI
Practice Address - Zip Code:53532-1421
Practice Address - Country:US
Practice Address - Phone:608-846-4736
Practice Address - Fax:608-846-6892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WI82550423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33266300Medicaid
5119397OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI1417999897Medicaid
000086028Medicare PIN