Provider Demographics
NPI:1982716809
Name:MEDICINE SHOPPE
Entity Type:Organization
Organization Name:MEDICINE SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY PLAN COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-993-6000
Mailing Address - Street 1:300 W SHAW AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-3680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 W SHAW AVE STE 114
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3680
Practice Address - Country:US
Practice Address - Phone:559-297-0251
Practice Address - Fax:559-297-4251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-05-29
Deactivation Date:2008-04-30
Deactivation Code:
Reactivation Date:2008-05-29
Provider Licenses
StateLicense IDTaxonomies
CAPHY224260333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0575247OtherOTHER ID NUMBER-COMMERCIAL NUMBER