Provider Demographics
NPI:1952481277
Name:MEDICINE SHOPPE OF DEKALB INC
Entity Type:Organization
Organization Name:MEDICINE SHOPPE OF DEKALB INC
Other - Org Name:THE MEDICINE STOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMBLYN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:515-758-8995
Mailing Address - Street 1:810 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-4410
Mailing Address - Country:US
Mailing Address - Phone:815-758-8995
Mailing Address - Fax:815-748-3784
Practice Address - Street 1:810 S 4TH ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4410
Practice Address - Country:US
Practice Address - Phone:815-758-8995
Practice Address - Fax:815-748-3784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL540100563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1449429OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1449429OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1449429OtherNCPDP PROVIDER IDENTIFICATION NUMBER