Basic Information
| Provider Information | |||||||||
| NPI: | 1467936138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCANN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6610 COOPER AVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535623354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083547093 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 HWY 138 | ||||||||
| Address2: | |||||||||
| City: | STOUGHTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088739262 | ||||||||
| FaxNumber: | 6088735496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2018 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 11028 | WI | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 11028 | 01 | WI | PHARMACIST | OTHER | 1189627 | 01 | NABP | OTHER |