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General NPI Number Information
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NPI Number | 1093824880
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Entity Type | Organization
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Legal Business Name | MC5 INC
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 12/09/2016
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Provider Practice Location Address
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Address Line | 1173 W MAIN ST
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City | WHITEWATER
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State | WI
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Zip | 53190-1672
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Country | US
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Telephone | 262-473-5065
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Fax | 262-473-7357
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Provider Business Mailing Address
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Address Line | 694 S WELLS ST
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City | LAKE GENEVA
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State | WI
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Zip | 53147-2106
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | JAMES MCCULLOUGH
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Credential |
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Telephone | 262-248-8582
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 6604042
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License Number State | WI
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