Provider Demographics
NPI:1952890493
Name:MAG RX LLC
Entity Type:Organization
Organization Name:MAG RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLOM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:920-897-5333
Mailing Address - Street 1:633 BUSINESS 141 N
Mailing Address - Street 2:
Mailing Address - City:COLEMAN
Mailing Address - State:WI
Mailing Address - Zip Code:54112-9416
Mailing Address - Country:US
Mailing Address - Phone:920-897-5333
Mailing Address - Fax:920-897-5451
Practice Address - Street 1:633 BUSINESS 141 N
Practice Address - Street 2:
Practice Address - City:COLEMAN
Practice Address - State:WI
Practice Address - Zip Code:54112-9416
Practice Address - Country:US
Practice Address - Phone:920-897-5333
Practice Address - Fax:920-897-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WI9511-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies