Provider Demographics
NPI:1447222799
Name:PHILLIPS TOMAH PHARMACY INC
Entity Type:Organization
Organization Name:PHILLIPS TOMAH PHARMACY INC
Other - Org Name:PHILLIPS TOMAH PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACARDY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:800-343-3784
Mailing Address - Street 1:PO BOX 136
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-0136
Mailing Address - Country:US
Mailing Address - Phone:800-343-3784
Mailing Address - Fax:608-847-5004
Practice Address - Street 1:1004 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-2002
Practice Address - Country:US
Practice Address - Phone:608-372-4115
Practice Address - Fax:608-372-4116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI7805-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2113172OtherPK
WI33234400Medicaid