Provider Demographics
NPI:1598768137
Name:MD GROUP LLC
Entity Type:Organization
Organization Name:MD GROUP LLC
Other - Org Name:EVANSVILLE HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-992-6800
Mailing Address - Street 1:PO BOX 245
Mailing Address - Street 2:333 LOWVILLE ROAD
Mailing Address - City:RIO
Mailing Address - State:WI
Mailing Address - Zip Code:53960-0245
Mailing Address - Country:US
Mailing Address - Phone:920-992-6800
Mailing Address - Fax:920-992-6801
Practice Address - Street 1:21 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1143
Practice Address - Country:US
Practice Address - Phone:608-882-4550
Practice Address - Fax:608-882-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
WI8433-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2114593OtherPK
WI33266200Medicaid
000086029Medicare PIN
5117874OtherNCPDP PROVIDER IDENTIFICATION NUMBER