Provider Demographics
NPI:1790778967
Name:MAYER DRUG INC
Entity Type:Organization
Organization Name:MAYER DRUG INC
Other - Org Name:LARSEN MAYER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-658-8124
Mailing Address - Street 1:3535 30TH AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1632
Mailing Address - Country:US
Mailing Address - Phone:262-658-8124
Mailing Address - Fax:262-564-8667
Practice Address - Street 1:3535 30TH AVE
Practice Address - Street 2:STE 103
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1632
Practice Address - Country:US
Practice Address - Phone:262-658-8124
Practice Address - Fax:262-564-8667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8019-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5102392OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI3305290033069300Medicaid
0750250001Medicare NSC