Provider Demographics
NPI:1629520879
Name:MBMC MAUSTON PHILLIPS, LLC
Entity Type:Organization
Organization Name:MBMC MAUSTON PHILLIPS, LLC
Other - Org Name:PHILLIPS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:O'KEEFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-847-6161
Mailing Address - Street 1:123 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-1344
Mailing Address - Country:US
Mailing Address - Phone:608-847-5949
Mailing Address - Fax:608-847-5004
Practice Address - Street 1:123 E STATE ST
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-1344
Practice Address - Country:US
Practice Address - Phone:608-847-5949
Practice Address - Fax:608-847-5004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-03
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9434-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy