1518901826 NPI number — FAMILY PHARMACY OF OLYPHANT INC

Table of content: (NPI 1518901826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518901826 NPI number — FAMILY PHARMACY OF OLYPHANT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY PHARMACY OF OLYPHANT INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY PHARMACY OF OLYPHANT INC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518901826
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 DELAWARE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYPHANT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18447-1518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-487-4447
Provider Business Mailing Address Fax Number:
570-487-2750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 DELAWARE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYPHANT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18447-1518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-487-4447
Provider Business Practice Location Address Fax Number:
570-487-2750
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOUGHERTY
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-848-1845

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PP415636L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3977216 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01793380 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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