Provider Demographics
NPI:1730121039
Name:MD GROUP II LLC
Entity Type:Organization
Organization Name:MD GROUP II LLC
Other - Org Name:NEW GLARUS 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:L
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 1:1101 HWY 69 STE 7
Practice Address - Street 2:
Practice Address - City:NEW GLARUS
Practice Address - State:WI
Practice Address - Zip Code:53574
Practice Address - Country:US
Practice Address - Phone:608-527-2517
Practice Address - Fax:608-527-2107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336S0011X
WI8528-0423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5108394OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI33275600Medicaid
000086018Medicare PIN
5376730002Medicare NSC