Healthcare Provider Details

I. General information

NPI: 1164932091
Provider Name (Legal Business Name): MABIE PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LIBERTY ST # 106
DEERFIELD WI
53531-9458
US

IV. Provider business mailing address

PO BOX 406
DEERFIELD WI
53531-0406
US

V. Phone/Fax

Practice location:
  • Phone: 608-764-1500
  • Fax: 608-764-1600
Mailing address:
  • Phone: 608-764-1500
  • Fax: 608-764-1600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number9485-042
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number9485-042
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number9485-042
License Number StateWI

VIII. Authorized Official

Name: MR. MATTHEW RYAN MABIE
Title or Position: OWNER
Credential: RPH
Phone: 608-347-5420