Provider Demographics
NPI:1104285907
Name:MOE DRUGS LLC
Entity type:Organization
Organization Name:MOE DRUGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMD
Authorized Official - Prefix:
Authorized Official - First Name:SETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-639-1384
Mailing Address - Street 1:1790 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:THREE LAKES
Mailing Address - State:WI
Mailing Address - Zip Code:54562-9046
Mailing Address - Country:US
Mailing Address - Phone:715-546-3266
Mailing Address - Fax:715-546-2912
Practice Address - Street 1:1790 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:THREE LAKES
Practice Address - State:WI
Practice Address - Zip Code:54562-9046
Practice Address - Country:US
Practice Address - Phone:715-546-3266
Practice Address - Fax:715-546-2912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI9400-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158870OtherPK
WI100055480Medicaid