Provider Demographics
NPI:1871651828
Name:MEDICINE SHOPPE 1018 LLC
Entity Type:Organization
Organization Name:MEDICINE SHOPPE 1018 LLC
Other - Org Name:MEDICINE SHOPPE 1018
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMER
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-412-7442
Mailing Address - Street 1:900 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-4048
Mailing Address - Country:US
Mailing Address - Phone:740-653-7779
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-4048
Practice Address - Country:US
Practice Address - Phone:740-653-7779
Practice Address - Fax:740-653-8265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 333600000X
OH0209363003336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0340229Medicaid
2072053OtherPK
0289050002Medicare NSC
OH0254791Medicaid
OHBC4959764OtherDEA #