Healthcare Provider Details

I. General information

NPI: 1184353807
Provider Name (Legal Business Name): PORT FAMILY PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 N WISCONSIN ST
PORT WASHINGTON WI
53074-1207
US

IV. Provider business mailing address

1021 N WISCONSIN ST
PORT WASHINGTON WI
53074-1207
US

V. Phone/Fax

Practice location:
  • Phone: 262-261-3900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL J VINEBURG
Title or Position: OWNER
Credential: PHARMD.
Phone: 262-261-3900