Provider Demographics
NPI:1538609292
Name:MEQUON FAMILY PHARMACY INC
Entity type:Organization
Organization Name:MEQUON FAMILY PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUGURDUMOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-581-0411
Mailing Address - Street 1:1424 W MEQUON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3226
Mailing Address - Country:US
Mailing Address - Phone:262-581-0411
Mailing Address - Fax:262-923-1002
Practice Address - Street 1:1424 W MEQUON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3226
Practice Address - Country:US
Practice Address - Phone:262-581-0411
Practice Address - Fax:262-923-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168769OtherPK