MEDICARE: MEDICATE PHARMACY SHOPPES INC

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	333600000X	Pharmacy	BY4765472	IL

General Provider Information

NPI Number	:	1598855926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICATE PHARMACY SHOPPES INC

Provider Business Mailing Address
First Line	:	7602 STATE ST
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62203-1708
Country	:	US
Telephone Number	:	618-397-3331
Fax Number	:	618-397-6050

Provider Business Practice Location Address
First Line	:	7602 STATE ST
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62203-1708
Country	:	US
Telephone Number	:	618-397-3331
Fax Number	:	618-397-6050

Authorized Official
Title or Position	:	OWNER PHARMACIST
Name	:	MR. LAWRENCE L WISEMAN JR.
Credential	:	PHARMACIST
Telephone Number	:	618-397-3331

Provider Enumeration Date	:	10/14/2006
Last Update Date	:	08/22/2020

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