Healthcare Provider Details

I. General information

NPI: 1659670800
Provider Name (Legal Business Name): MARC A VAUGHAN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2011
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N171W21840 CAYMUS CT
JACKSON WI
53037-1211
US

IV. Provider business mailing address

N171W21840 CAYMUS CT
JACKSON WI
53037-1211
US

V. Phone/Fax

Practice location:
  • Phone: 262-677-1401
  • Fax:
Mailing address:
  • Phone: 262-677-1401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.293069
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number18274-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: