Healthcare Provider Details

I. General information

NPI: 1568501609
Provider Name (Legal Business Name): MILLER PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N ROCHESTER ST
MUKWONAGO WI
53149-1142
US

IV. Provider business mailing address

801 N ROCHESTER ST
MUKWONAGO WI
53149-1142
US

V. Phone/Fax

Practice location:
  • Phone: 262-363-4001
  • Fax: 262-363-5699
Mailing address:
  • Phone: 262-363-4001
  • Fax: 262-363-5699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5677042
License Number StateWI

VIII. Authorized Official

Name: STEPHEN DOUGLAS HERBST
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 262-363-4001