Provider Demographics
NPI:1558777938
Name:MEDICATE PHARMACY INC
Entity Type:Organization
Organization Name:MEDICATE PHARMACY INC
Other - Org Name:MEDICATE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIBHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SURANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-624-3545
Mailing Address - Street 1:2741 W LAYTON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2600
Mailing Address - Country:US
Mailing Address - Phone:414-539-3912
Mailing Address - Fax:414-539-3913
Practice Address - Street 1:2741 W LAYTON AVE STE 102
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2600
Practice Address - Country:US
Practice Address - Phone:414-539-3912
Practice Address - Fax:414-539-3913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
WI9272-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100038961Medicaid
2146746OtherPK