Provider Demographics
NPI:1982603189
Name:MEDICAL SHOPPE LTD
Entity Type:Organization
Organization Name:MEDICAL SHOPPE LTD
Other - Org Name:STEPHENS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:570-253-7700
Mailing Address - Street 1:1101 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431
Mailing Address - Country:US
Mailing Address - Phone:570-253-7770
Mailing Address - Fax:570-251-7809
Practice Address - Street 1:1101 MAIN ST
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1907
Practice Address - Country:US
Practice Address - Phone:570-253-7770
Practice Address - Fax:570-251-7809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP414702L333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007436710003Medicaid
PA1007436710003Medicaid