Provider Demographics
NPI:1376833970
Name:MEDICINE SHOPPE LONG TERM CARE
Entity Type:Organization
Organization Name:MEDICINE SHOPPE LONG TERM CARE
Other - Org Name:MEDICINE SHOPPE LONG TERM CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-679-9227
Mailing Address - Street 1:900 E MOUNT VERNON ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-1228
Mailing Address - Country:US
Mailing Address - Phone:606-679-9227
Mailing Address - Fax:606-679-1358
Practice Address - Street 1:900 E MOUNT VERNON ST UNIT B
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-1228
Practice Address - Country:US
Practice Address - Phone:606-679-9227
Practice Address - Fax:606-679-1358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
KYP074483336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130183OtherPK