MEDICARE: MEDICINE PLACE INC 1008 LAMAR ST SWEETWATER TX

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	10882	TX
2	333600000X	Pharmacy	10882	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4567814	OTHER	TX	NCPDP# (FORMERLY NABP#)
3	10882	OTHER	TX	TX STATE BOARD LIC #

General Provider Information

NPI Number	:	1265424832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICINE PLACE INC 1008 LAMAR ST SWEETWATER TX

Provider Business Mailing Address
First Line	:	2250 CHESTNUT ST.
Second Line	:
City	:	COLORADO CITY
State	:	TX
Zip	:	79512-3485
Country	:	US
Telephone Number	:	325-728-3489
Fax Number	:	325-728-8683

Provider Business Practice Location Address
First Line	:	2250 CHESTNUT ST.
Second Line	:
City	:	COLORADO CITY
State	:	TX
Zip	:	79512-3485
Country	:	US
Telephone Number	:	325-728-3489
Fax Number	:	325-728-8683

Authorized Official
Title or Position	:	PHARMACIST IN CHARGE/V.P./OWNER
Name	:	MR. PAUL GILBERT JOHNSON
Credential	:	R.PH.
Telephone Number	:	325-728-3489

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	03/07/2023

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