Provider Demographics
NPI:1770589897
Name:FMPS LLC
Entity type:Organization
Organization Name:FMPS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:
Authorized Official - Last Name:STILLWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-270-0038
Mailing Address - Street 1:121 FRENCH ST
Mailing Address - Street 2:
Mailing Address - City:PESHTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54157-1215
Mailing Address - Country:US
Mailing Address - Phone:715-582-4140
Mailing Address - Fax:715-582-4196
Practice Address - Street 1:121 FRENCH ST
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157-1215
Practice Address - Country:US
Practice Address - Phone:715-582-4140
Practice Address - Fax:715-582-4196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9303-42333600000X
332B00000X
WI77633336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Yes333600000XSuppliersPharmacyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150999OtherPK
WI5124730OtherNCPDP #
WI33231000Medicaid