Provider Demographics
NPI:1598855926
Name:MEDICATE PHARMACY SHOPPES INC
Entity Type:Organization
Organization Name:MEDICATE PHARMACY SHOPPES INC
Other - Org Name:YOCISS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:618-397-3331
Mailing Address - Street 1:7602 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-1708
Mailing Address - Country:US
Mailing Address - Phone:618-397-3331
Mailing Address - Fax:618-397-6050
Practice Address - Street 1:7602 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62203-1708
Practice Address - Country:US
Practice Address - Phone:618-397-3331
Practice Address - Fax:618-397-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBY4765472333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
1401671Medicare UPIN
IL=========001Medicaid