Healthcare Provider Details

I. General information

NPI: 1538609292
Provider Name (Legal Business Name): MEQUON FAMILY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 W MEQUON RD
MEQUON WI
53092-3226
US

IV. Provider business mailing address

1424 W MEQUON RD
MEQUON WI
53092-3226
US

V. Phone/Fax

Practice location:
  • Phone: 262-581-0411
  • Fax: 262-923-1002
Mailing address:
  • Phone: 262-581-0411
  • Fax: 262-923-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: LAURA MUGURDUMOVA
Title or Position: CEO
Credential:
Phone: 262-581-0411