Provider Demographics
NPI:1962506915
Name:MIKE FLINT ENTERPRISES INC
Entity Type:Organization
Organization Name:MIKE FLINT ENTERPRISES INC
Other - Org Name:MALLATT'S PHARMACY AND COSTUMES #102
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FLINT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:608-310-9922
Mailing Address - Street 1:233 S CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-1249
Mailing Address - Country:US
Mailing Address - Phone:608-849-7888
Mailing Address - Fax:608-849-7474
Practice Address - Street 1:233 S CENTURY AVE
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-1249
Practice Address - Country:US
Practice Address - Phone:608-849-7888
Practice Address - Fax:608-849-7474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WI9155-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1962506915Medicaid
WI33015500Medicaid
2137291OtherPK