=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326740432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILWAUKEE PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2023
-----------------------------------------------------
Last Update Date | 02/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1134 W NORTH AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53205-1333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-442-8760
-----------------------------------------------------
Fax | 414-442-8761
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2400 W BURLEIGH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53206-1201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-442-8760
-----------------------------------------------------
Fax | 414-442-8761
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JAMAL ELZEIBAGH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-344-5024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------