=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437313384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MC 5 INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2008
-----------------------------------------------------
Last Update Date | 08/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1173 W MAIN ST STE F
-----------------------------------------------------
City | WHITEWATER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53190-1672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-473-5087
-----------------------------------------------------
Fax | 262-473-7357
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1173 W MAIN ST STE F
-----------------------------------------------------
City | WHITEWATER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53190-1672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-473-5087
-----------------------------------------------------
Fax | 262-473-7357
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT MCCULLOUGH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-473-5087
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 885142
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------