Provider Demographics
NPI:1255479242
Name:PAUL R GROUT
Entity Type:Organization
Organization Name:PAUL R GROUT
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GROUT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:585-798-1212
Mailing Address - Street 1:142 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:NY
Mailing Address - Zip Code:14103-1621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-1621
Practice Address - Country:US
Practice Address - Phone:585-798-1212
Practice Address - Fax:585-798-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022120333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3335951OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY00610586Medicaid
NY00610586Medicaid
NY00610586Medicaid