Provider Demographics
NPI:1578634408
Name:MORTON DRUG CO INC
Entity Type:Organization
Organization Name:MORTON DRUG CO INC
Other - Org Name:MORTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CORPORATE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-727-8882
Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54957-0778
Mailing Address - Country:US
Mailing Address - Phone:920-727-3853
Mailing Address - Fax:920-727-3867
Practice Address - Street 1:N1788 LILY OF THE VALLEY DR
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942-9103
Practice Address - Country:US
Practice Address - Phone:920-757-3096
Practice Address - Fax:920-757-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33290200Medicaid
5129398OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI33290200Medicaid