Provider Demographics
NPI:1295826741
Name:MINERVA PHARMACY INC
Entity Type:Organization
Organization Name:MINERVA PHARMACY INC
Other - Org Name:THE MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANICH
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:330-453-4804
Mailing Address - Street 1:2601 TUSCARAWAS ST W
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4603
Mailing Address - Country:US
Mailing Address - Phone:330-453-4804
Mailing Address - Fax:330-453-7688
Practice Address - Street 1:251 EAST ST
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-1617
Practice Address - Country:US
Practice Address - Phone:330-868-6200
Practice Address - Fax:330-453-7688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-19719332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3656292OtherNAPB
OH0853901Medicaid
OH3656292OtherNAPB