Healthcare Provider Details

I. General information

NPI: 1780866509
Provider Name (Legal Business Name): THE MEDICINE STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CANDLEWOOD RD
BAY SHORE NY
11706-2351
US

IV. Provider business mailing address

5 CANDLEWOOD RD
BAY SHORE NY
11706-2351
US

V. Phone/Fax

Practice location:
  • Phone: 631-300-4670
  • Fax: 631-300-4673
Mailing address:
  • Phone: 631-300-4670
  • Fax: 631-300-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number028674
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DEMETRIS PAVLOU
Title or Position: PRESIDENT
Credential:
Phone: 631-300-4670