1851476949 NPI number — BRACEY'S MOUNT POCONO, INC.

Table of content: (NPI 1851476949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851476949 NPI number — BRACEY'S MOUNT POCONO, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRACEY'S MOUNT POCONO, 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:
BILL'S SHOPRITE PHARMACY MT. POCONO
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:
1851476949
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
921 DRINKER TPKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON TOWNSHIP
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18444-7947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-842-7461
Provider Business Mailing Address Fax Number:
570-842-6520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
89 STATE ROUTE 940
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT POCONO
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18344-1426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-839-5340
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FIGUEROA-RIVERA
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
THIRD PARTY ADMINISTRATOR
Authorized Official Telephone Number:
732-521-8439

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PP481373 , 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: 1009983850001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3983233 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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