Provider Demographics
NPI:1366952293
Name:MABIE PHARMACY, LLC
Entity type:Organization
Organization Name:MABIE PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MABIE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-347-5420
Mailing Address - Street 1:4880 LARSON BEACH RD
Mailing Address - Street 2:
Mailing Address - City:MC FARLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53558-8724
Mailing Address - Country:US
Mailing Address - Phone:608-838-7455
Mailing Address - Fax:608-838-8329
Practice Address - Street 1:4880 LARSON BEACH RD
Practice Address - Street 2:
Practice Address - City:MC FARLAND
Practice Address - State:WI
Practice Address - Zip Code:53558-8724
Practice Address - Country:US
Practice Address - Phone:608-838-7455
Practice Address - Fax:608-838-8329
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MABIE PHARMACY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-05
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9484-0423336L0003X, 3336S0011X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1366952293Medicaid
WI9484-042OtherSTATE OF WISCONSIN PHARMACY LICENSE
WI1366952293Medicaid