MEDICARE: E.A. MCCULLOUGH, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	4700	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043329824
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	E.A. MCCULLOUGH, INC.

Provider Business Mailing Address
First Line	:	694 S WELLS ST
Second Line	:
City	:	LAKE GENEVA
State	:	WI
Zip	:	53147-2106
Country	:	US
Telephone Number	:	262-248-8582
Fax Number	:	262-248-8593

Provider Business Practice Location Address
First Line	:	269 BROAD ST
Second Line	:
City	:	LAKE GENEVA
State	:	WI
Zip	:	53147-1809
Country	:	US
Telephone Number	:	262-248-6226
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JAMES EDWARD MCCULLOUGH
Credential	:	RPH
Telephone Number	:	262-248-6226

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	02/04/2008

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