Provider Demographics
NPI:1982781308
Name:MICKLESEN DRUG INC
Entity Type:Organization
Organization Name:MICKLESEN DRUG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH PHARMACIST IN CH
Authorized Official - Phone:715-386-3344
Mailing Address - Street 1:530 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016
Mailing Address - Country:US
Mailing Address - Phone:715-386-3344
Mailing Address - Fax:715-386-5198
Practice Address - Street 1:530 SECOND ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016
Practice Address - Country:US
Practice Address - Phone:715-386-3344
Practice Address - Fax:715-386-5198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4862042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5106275OtherNAPB
WI33003000Medicaid
WI33003000Medicaid
AM3909136OtherDEA