Provider Demographics
NPI:1962514976
Name:MEDICINE SHOPPE
Entity type:Organization
Organization Name:MEDICINE SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGALAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-735-5114
Mailing Address - Street 1:69 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:NANTICOKE
Mailing Address - State:PA
Mailing Address - Zip Code:18634-1553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:69 N MARKET ST
Practice Address - Street 2:
Practice Address - City:NANTICOKE
Practice Address - State:PA
Practice Address - Zip Code:18634-1553
Practice Address - Country:US
Practice Address - Phone:570-735-5114
Practice Address - Fax:570-735-6624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP412490L333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3942439OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3942439OtherOTHER ID NUMBER-COMMERCIAL NUMBER