Provider Demographics
NPI:1831194588
Name:MED-SHOPPE PHARMACY INC
Entity type:Organization
Organization Name:MED-SHOPPE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-329-6466
Mailing Address - Street 1:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-0966
Mailing Address - Country:US
Mailing Address - Phone:812-275-5949
Mailing Address - Fax:812-277-3632
Practice Address - Street 1:2900 16TH ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3510
Practice Address - Country:US
Practice Address - Phone:812-275-1340
Practice Address - Fax:812-275-1450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-18
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN600057763336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200463100AMedicaid
2024681OtherPK
IN200463100AMedicaid