Provider Demographics
NPI:1356370217
Name:MEDICINE STORE LLC
Entity type:Organization
Organization Name:MEDICINE STORE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARM
Authorized Official - Phone:913-369-2100
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-0580
Mailing Address - Country:US
Mailing Address - Phone:913-369-2100
Mailing Address - Fax:913-369-2101
Practice Address - Street 1:760 NORTHSTAR CT
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-8933
Practice Address - Country:US
Practice Address - Phone:913-369-2100
Practice Address - Fax:913-369-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KS2-102133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200574500CMedicaid
KS200574500DMedicaid
2025539OtherPK
KS200574500CMedicaid