Provider Demographics
NPI:1750493698
Name:MEDICINE MAN PHARMACY INC
Entity Type:Organization
Organization Name:MEDICINE MAN PHARMACY INC
Other - Org Name:MEDICINE MAN PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-666-2502
Mailing Address - Street 1:1114 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2605
Mailing Address - Country:US
Mailing Address - Phone:208-666-2502
Mailing Address - Fax:208-667-5921
Practice Address - Street 1:1114 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2605
Practice Address - Country:US
Practice Address - Phone:208-666-2502
Practice Address - Fax:208-667-5921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID657RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002541100Medicaid
ID002541200Medicaid
2020458OtherPK
ID002541100Medicaid