Provider Demographics
NPI:1659316792
Name:MED SHOP PHARMACY INC
Entity Type:Organization
Organization Name:MED SHOP PHARMACY INC
Other - Org Name:THE MED-SHOP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-680-2600
Mailing Address - Street 1:825 US HIGHWAY 271 N
Mailing Address - Street 2:
Mailing Address - City:GILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75644-5580
Mailing Address - Country:US
Mailing Address - Phone:903-680-2600
Mailing Address - Fax:903-680-2605
Practice Address - Street 1:825 US HIGHWAY 271 N
Practice Address - Street 2:
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75644-5580
Practice Address - Country:US
Practice Address - Phone:903-680-2600
Practice Address - Fax:903-680-2605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
TX230423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2096845OtherPK
TX148119Medicaid