Provider Demographics
NPI:1417319625
Name:SHAMOKIN PHARMACY LLC
Entity Type:Organization
Organization Name:SHAMOKIN PHARMACY LLC
Other - Org Name:THE MEDICINE SHOPPE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHETAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-648-5242
Mailing Address - Street 1:605 N SHAMOKIN ST
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN
Mailing Address - State:PA
Mailing Address - Zip Code:17872-6719
Mailing Address - Country:US
Mailing Address - Phone:570-648-5242
Mailing Address - Fax:570-648-3606
Practice Address - Street 1:605 N SHAMOKIN ST
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-6719
Practice Address - Country:US
Practice Address - Phone:570-648-5242
Practice Address - Fax:570-648-3606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-26
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP414448L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159095OtherPK
PA1031121840001Medicaid