Provider Demographics
NPI:1205997517
Name:SOURCE ONE HEALTHCARE A DIVISION OF PHILLIPS PHARMACIES
Entity type:Organization
Organization Name:SOURCE ONE HEALTHCARE A DIVISION OF PHILLIPS PHARMACIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACARDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-779-1276
Mailing Address - Street 1:123 E STATE ST
Mailing Address - Street 2:P.O. BOX 218
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-1344
Mailing Address - Country:US
Mailing Address - Phone:800-779-1276
Mailing Address - Fax:608-847-5739
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:800-779-1276
Practice Address - Fax:608-847-5739
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHILLIPS DRUG STORE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-12
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization