Provider Demographics
NPI:1386789915
Name:THE MEDICINE SHOPPE #1425
Entity type:Organization
Organization Name:THE MEDICINE SHOPPE #1425
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CREECH DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-841-9600
Mailing Address - Street 1:101 HWY 301 SOUTH
Mailing Address - Street 2:PO BOX 867
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-3447
Mailing Address - Country:US
Mailing Address - Phone:843-841-9600
Mailing Address - Fax:843-774-3860
Practice Address - Street 1:101 HWY 301 SOUTH
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-3447
Practice Address - Country:US
Practice Address - Phone:843-841-9600
Practice Address - Fax:843-774-3860
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MEDICINE SHOPPE #1425
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-21
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7462183500000X
333600000X
SC500034313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4219538OtherOTHER ID NUMBER
4219538OtherOTHER ID NUMBER-COMMERCIAL NUMBER