Provider Demographics
NPI:1639495237
Name:PHILLIPS TOTAL CARE PHARMACY INC.
Entity Type:Organization
Organization Name:PHILLIPS TOTAL CARE PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MACARDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-847-5949
Mailing Address - Street 1:125 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:608-847-5199
Practice Address - Street 1:125 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:608-847-5199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9001-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100009037Medicaid
5132181OtherNCPDP PROVIDER IDENTIFICATION NUMBER