Provider Demographics
NPI:1568501609
Name:MILLER PHARMACY, INC.
Entity Type:Organization
Organization Name:MILLER PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:HERBST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:262-363-4001
Mailing Address - Street 1:801 N ROCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-1142
Mailing Address - Country:US
Mailing Address - Phone:262-363-4001
Mailing Address - Fax:262-363-5699
Practice Address - Street 1:801 N ROCHESTER ST
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-1142
Practice Address - Country:US
Practice Address - Phone:262-363-4001
Practice Address - Fax:262-363-5699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5677042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33104700Medicaid
WI0716380001Medicare NSC