Healthcare Provider Details

I. General information

NPI: 1982716809
Provider Name (Legal Business Name): MEDICINE SHOPPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date: 04/30/2008
Reactivation Date: 05/29/2008

III. Provider practice location address

300 W SHAW AVE STE 114
CLOVIS CA
93612-3680
US

IV. Provider business mailing address

300 W SHAW AVE STE 114
CLOVIS CA
93612-3680
US

V. Phone/Fax

Practice location:
  • Phone: 559-297-0251
  • Fax: 559-297-4251
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY224260
License Number StateCA

VIII. Authorized Official

Name: DENA FERMAN
Title or Position: THIRD PARTY PLAN COORDINATOR
Credential:
Phone: 314-993-6000