Healthcare Provider Details

I. General information

NPI: 1083607923
Provider Name (Legal Business Name): MEDICINE SHOPPE 1088 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 N SANDUSKY AVE
BUCYRUS OH
44820-1806
US

IV. Provider business mailing address

345 N SANDUSKY AVE
BUCYRUS OH
44820-1806
US

V. Phone/Fax

Practice location:
  • Phone: 419-562-4222
  • Fax: 419-562-4516
Mailing address:
  • Phone: 419-562-4222
  • Fax: 419-562-4516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number02-735050
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateOH

VIII. Authorized Official

Name: TAMER IBRAHIM
Title or Position: PRESIDENT
Credential:
Phone: 330-412-7442