Healthcare Provider Details

I. General information

NPI: 1407265598
Provider Name (Legal Business Name): MODERN APOTHECARY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 6TH AVE
KENOSHA WI
53140-4104
US

IV. Provider business mailing address

5700 6TH AVE
KENOSHA WI
53140-4104
US

V. Phone/Fax

Practice location:
  • Phone: 262-997-9573
  • Fax: 262-997-9574
Mailing address:
  • Phone: 262-997-9573
  • Fax: 262-997-9574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number9274-42
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ERIN E MERRITT
Title or Position: OWNER
Credential: PHARMD
Phone: 262-997-9573