Provider Demographics
NPI:1992897052
Name:MCM PHARMACY INC
Entity type:Organization
Organization Name:MCM PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHCY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:308-384-9010
Mailing Address - Street 1:3224 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-2445
Mailing Address - Country:US
Mailing Address - Phone:308-384-9010
Mailing Address - Fax:308-384-9096
Practice Address - Street 1:3224 W 13TH ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-2445
Practice Address - Country:US
Practice Address - Phone:308-384-9010
Practice Address - Fax:308-384-9096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NE29103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131342OtherPK
NE10026068000Medicaid
NENA1967Medicare PIN
NE10026068000Medicaid