Provider Demographics
NPI:1225046501
Name:MEDICINE SHOPPE
Entity Type:Organization
Organization Name:MEDICINE SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONERTY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:732-367-5080
Mailing Address - Street 1:681 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5229
Mailing Address - Country:US
Mailing Address - Phone:732-367-5080
Mailing Address - Fax:732-367-5734
Practice Address - Street 1:681 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5229
Practice Address - Country:US
Practice Address - Phone:732-367-5080
Practice Address - Fax:732-367-5734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJRS006140003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3120627OtherOTHER ID NUMBER
NJ9004408Medicaid
NJ9004408Medicaid
NJ4841710001Medicare NSC