=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104916220
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MORTON DRUG CO INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 09/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1855 S KOELLER ST
-----------------------------------------------------
City | OSHKOSH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54902-6214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-223-7390
-----------------------------------------------------
Fax | 920-223-7394
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 778
-----------------------------------------------------
City | NEENAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54957-0778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-727-3853
-----------------------------------------------------
Fax | 920-727-3867
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP CORPORATE SERVICES
-----------------------------------------------------
Name | JEFFREY BLANK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-727-8882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 7995-42
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------