Provider Demographics
NPI:1932345048
Name:MEDIC SHOP PHARMACY
Entity Type:Organization
Organization Name:MEDIC SHOP PHARMACY
Other - Org Name:MEDIC SHOP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-875-7515
Mailing Address - Street 1:1000 BUSINESS 190
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-3285
Mailing Address - Country:US
Mailing Address - Phone:985-875-7515
Mailing Address - Fax:985-875-7544
Practice Address - Street 1:1000 BUSINESS 190
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-3285
Practice Address - Country:US
Practice Address - Phone:985-875-7515
Practice Address - Fax:985-875-7544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.006069-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118384OtherPK