Healthcare Provider Details

I. General information

NPI: 1205997517
Provider Name (Legal Business Name): SOURCE ONE HEALTHCARE A DIVISION OF PHILLIPS PHARMACIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E STATE ST
MAUSTON WI
53948-1344
US

IV. Provider business mailing address

123 E STATE ST P.O. BOX 218
MAUSTON WI
53948-1344
US

V. Phone/Fax

Practice location:
  • Phone: 800-779-1276
  • Fax: 608-847-5739
Mailing address:
  • Phone: 800-779-1276
  • Fax: 608-847-5739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: WAYNE MACARDY
Title or Position: PRESIDENT
Credential:
Phone: 800-779-1276