Provider Demographics
NPI:1720231608
Name:THE MEDICINE SHOPPE
Entity Type:Organization
Organization Name:THE MEDICINE SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:618-842-6007
Mailing Address - Street 1:1116 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-2324
Mailing Address - Country:US
Mailing Address - Phone:618-842-6007
Mailing Address - Fax:618-842-4816
Practice Address - Street 1:1116 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-2324
Practice Address - Country:US
Practice Address - Phone:618-842-6007
Practice Address - Fax:618-842-4816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000745332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL4548420001Medicare NSC