Provider Demographics
NPI:1083607923
Name:MEDICINE SHOPPE 1088 LLC
Entity Type:Organization
Organization Name:MEDICINE SHOPPE 1088 LLC
Other - Org Name:MEDICINE SHOPPE 1088
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMER
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-412-7442
Mailing Address - Street 1:345 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:OH
Mailing Address - Zip Code:44820-1806
Mailing Address - Country:US
Mailing Address - Phone:419-562-4222
Mailing Address - Fax:419-562-4516
Practice Address - Street 1:345 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1806
Practice Address - Country:US
Practice Address - Phone:419-562-4222
Practice Address - Fax:419-562-4516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02-735050333600000X
OH3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3654298OtherNCPDP #
OHBM2473774OtherDEA #
OH0932334Medicaid
OH0375060001Medicare NSC
OHBM2473774OtherDEA #