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General NPI Number Information
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NPI Number | 1790857597
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Entity Type | Organization
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Legal Business Name | MEDICINE MAN INC
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 02/03/2012
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Provider Practice Location Address
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Address Line | 400 HUNTINGDON PIKE SUITE A
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City | ROCKLEDGE
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State | PA
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Zip | 19046-4431
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Country | US
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Telephone | 215-663-1755
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Fax | 215-663-1737
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Provider Business Mailing Address
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Address Line | 400 HUNTINGDON PIKE SUITE A
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City | ROCKLEDGE
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State | PA
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Zip | 19046-4431
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Country | US
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Telephone | 215-663-1755
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Fax | 215-663-1737
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Authorized Official
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Title or Position | OWNER
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Name | ROBERT REIVER
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Credential | RPH
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Telephone | 215-663-1755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PP413738L
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License Number State | PA
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