Provider Demographics
NPI:1720009780
Name:MEDICINE STOP INC
Entity Type:Organization
Organization Name:MEDICINE STOP INC
Other - Org Name:THE MEDICINE STOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JAELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PROFFIT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:830-896-7440
Mailing Address - Street 1:1000 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-3565
Mailing Address - Country:US
Mailing Address - Phone:830-896-7440
Mailing Address - Fax:830-896-2221
Practice Address - Street 1:1000 MAIN ST
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-3507
Practice Address - Country:US
Practice Address - Phone:830-896-7440
Practice Address - Fax:830-896-2221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX158813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144035Medicaid
2100398OtherPK