Provider Demographics
NPI:1750353850
Name:PHILLIPS DRUG STORE
Entity type:Organization
Organization Name:PHILLIPS DRUG STORE
Other - Org Name:
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:RPH
Authorized Official - Phone:608-847-5949
Mailing Address - Street 1:PO BOX 136
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-0136
Mailing Address - Country:US
Mailing Address - Phone:608-847-6155
Mailing Address - Fax:608-847-2126
Practice Address - Street 1:1040 DIVISION ST
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948
Practice Address - Country:US
Practice Address - Phone:608-847-6155
Practice Address - Fax:608-847-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7013042333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33167100Medicaid
WI33167100Medicaid