Healthcare Provider Details

I. General information

NPI: 1053873521
Provider Name (Legal Business Name): MABIE PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S LUDINGTON ST
COLUMBUS WI
53925-1516
US

IV. Provider business mailing address

2108 UPHOFF RD
COTTAGE GROVE WI
53527-9475
US

V. Phone/Fax

Practice location:
  • Phone: 920-623-2701
  • Fax: 920-623-3706
Mailing address:
  • Phone: 608-347-5420
  • Fax: 608-839-3336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW RYAN MABIE
Title or Position: OWNER
Credential: RPH
Phone: 608-839-3335