Provider Demographics
NPI:1336295245
Name:MIDE INC.
Entity type:Organization
Organization Name:MIDE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOIOFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-781-3058
Mailing Address - Street 1:600 E PIONEER ST STE 3
Mailing Address - Street 2:
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-1662
Mailing Address - Country:US
Mailing Address - Phone:715-478-3369
Mailing Address - Fax:715-478-3945
Practice Address - Street 1:600 E PIONEER ST STE 3
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-1662
Practice Address - Country:US
Practice Address - Phone:715-478-3369
Practice Address - Fax:715-478-3945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7069042183500000X
333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33134200Medicaid
WI33134200Medicaid