Provider Demographics
NPI:1720316029
Name:BELLEVUE MEDICINE SHOPPE
Entity Type:Organization
Organization Name:BELLEVUE MEDICINE SHOPPE
Other - Org Name:CHAMPION MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD-DOCTORATE
Authorized Official - Phone:330-847-8000
Mailing Address - Street 1:4619 MAHONING AVE.
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483
Mailing Address - Country:US
Mailing Address - Phone:330-847-8000
Mailing Address - Fax:330-847-7708
Practice Address - Street 1:4619 MAHONING AVE.
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483
Practice Address - Country:US
Practice Address - Phone:330-847-8000
Practice Address - Fax:330-847-7708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH022001250333600000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
6395340001Medicare NSC