Provider Demographics
NPI:1780866509
Name:THE MEDICINE STORE INC
Entity Type:Organization
Organization Name:THE MEDICINE STORE INC
Other - Org Name:HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVLOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-300-4670
Mailing Address - Street 1:5 CANDLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-2351
Mailing Address - Country:US
Mailing Address - Phone:631-300-4670
Mailing Address - Fax:631-300-4673
Practice Address - Street 1:5 CANDLEWOOD RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-2351
Practice Address - Country:US
Practice Address - Phone:631-300-4670
Practice Address - Fax:631-300-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
NY0286743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2069992OtherPK
NY2936345Medicaid