Provider Demographics
NPI:1497749915
Name:MEDICINE CHEST 114 LLC
Entity Type:Organization
Organization Name:MEDICINE CHEST 114 LLC
Other - Org Name:GOODS MEDICINE CHEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-885-0821
Mailing Address - Street 1:PO BOX 6397
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6397
Mailing Address - Country:US
Mailing Address - Phone:903-885-0821
Mailing Address - Fax:903-885-1024
Practice Address - Street 1:807 S BECKHAM AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1905
Practice Address - Country:US
Practice Address - Phone:903-592-8283
Practice Address - Fax:903-885-1024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261823336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX466551Medicaid
2102545OtherPK
TX466551Medicaid