Provider Demographics
NPI:1811906720
Name:SERVE YOU CUSTOM PRESCRIPTION MANAGEMENT INC
Entity type:Organization
Organization Name:SERVE YOU CUSTOM PRESCRIPTION MANAGEMENT INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-410-8101
Mailing Address - Street 1:10201 W INNOVATION DR
Mailing Address - Street 2:STE 600
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4822
Mailing Address - Country:US
Mailing Address - Phone:800-759-3203
Mailing Address - Fax:
Practice Address - Street 1:10201 W INNOVATION DR
Practice Address - Street 2:STE 600
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4822
Practice Address - Country:US
Practice Address - Phone:800-759-3203
Practice Address - Fax:866-494-0364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336S0011X, 3336M0002X
WI8840-42333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115245OtherPK
WI1811906720Medicaid
WI33272800Medicaid