Provider Demographics
NPI:1316019110
Name:THE MEDICINE SHOPPE
Entity Type:Organization
Organization Name:THE MEDICINE SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY PLAN COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-993-6000
Mailing Address - Street 1:1417 E AIRLINE RD
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-4111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1417 E AIRLINE RD
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-4111
Practice Address - Country:US
Practice Address - Phone:361-573-6385
Practice Address - Fax:361-573-1617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17002333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144412Medicaid
4533128OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TXBT4796706OtherDEA #