MEDICARE: MAYER DRUG 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	8019-42	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5102392	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790778967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAYER DRUG INC

Provider Business Mailing Address
First Line	:	3535 30TH AVE
Second Line	:	STE 103
City	:	KENOSHA
State	:	WI
Zip	:	53144-1632
Country	:	US
Telephone Number	:	262-658-8124
Fax Number	:	262-564-8667

Provider Business Practice Location Address
First Line	:	3535 30TH AVE
Second Line	:	STE 103
City	:	KENOSHA
State	:	WI
Zip	:	53144-1632
Country	:	US
Telephone Number	:	262-658-8124
Fax Number	:	262-564-8667

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAYMOND LARSEN
Credential	:
Telephone Number	:	262-658-8124

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	10/06/2010

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Directions to “MAYER DRUG INC ” Practice Location

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