Provider Demographics
NPI:1053873521
Name:MABIE PHARMACY, LLC
Entity type:Organization
Organization Name:MABIE PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MABIE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-839-3335
Mailing Address - Street 1:2108 UPHOFF RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9475
Mailing Address - Country:US
Mailing Address - Phone:608-347-5420
Mailing Address - Fax:608-839-3336
Practice Address - Street 1:100 S LUDINGTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1516
Practice Address - Country:US
Practice Address - Phone:920-623-2701
Practice Address - Fax:920-623-3706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053873521Medicaid
WI9661-042OtherSTATE PHARMACY LICENSE
WI9661-042OtherSTATE PHARMACY LICENSE