Provider Demographics
NPI:1023120953
Name:MEDICINE SHOPPE 917
Entity type:Organization
Organization Name:MEDICINE SHOPPE 917
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:K
Authorized Official - Last Name:KWOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-625-5015
Mailing Address - Street 1:3507 W WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-4170
Mailing Address - Country:US
Mailing Address - Phone:559-625-5015
Mailing Address - Fax:559-625-1987
Practice Address - Street 1:3507 W WALNUT AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-4170
Practice Address - Country:US
Practice Address - Phone:559-625-5015
Practice Address - Fax:559-625-1987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY40626333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0593497OtherNCPDP #
CAPHA406260Medicaid
0593497OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CABM4322816OtherDEA #
CAPHA406260Medicaid
0593497OtherNCPDP #