Provider Demographics
NPI:1508376682
Name:MABIE PHARMACY, LLC
Entity Type:Organization
Organization Name:MABIE PHARMACY, LLC
Other - Org Name:FORWARD PHARMACY OF COTTAGE GROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MABIE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-347-5420
Mailing Address - Street 1:429 W COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9385
Mailing Address - Country:US
Mailing Address - Phone:608-839-3335
Mailing Address - Fax:608-839-3336
Practice Address - Street 1:429 W COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:WI
Practice Address - Zip Code:53527-9385
Practice Address - Country:US
Practice Address - Phone:608-839-3335
Practice Address - Fax:608-839-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9483-0423336C0003X, 3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9483-042OtherSTATE LICENSE NUMBER
WI1508376682Medicaid
WI1508376682Medicaid