Healthcare Provider Details

I. General information

NPI: 1356370217
Provider Name (Legal Business Name): MEDICINE STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 NORTHSTAR CT
TONGANOXIE KS
66086-8933
US

IV. Provider business mailing address

PO BOX 580
TONGANOXIE KS
66086-0580
US

V. Phone/Fax

Practice location:
  • Phone: 913-369-2100
  • Fax: 913-369-2101
Mailing address:
  • Phone: 913-369-2100
  • Fax: 913-369-2101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2-10213
License Number StateKS

VIII. Authorized Official

Name: TERRI TAYLOR
Title or Position: MANAGER/PHARMACIST IN CHARGE
Credential: BS PHARM
Phone: 913-369-2100