1003086455 NPI number — ST LUKES HOMESTAR SERVICES LLC

Table of content: (NPI 1003086455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003086455 NPI number — ST LUKES HOMESTAR SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LUKES HOMESTAR SERVICES LLC
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:
Provider Other Organization Name Type Code:
6
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:
1003086455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 S COMMERCE WAY
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
BETHLEHEM
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18017-8917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-954-4210
Provider Business Mailing Address Fax Number:
610-882-0246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 S COMMERCE WAY
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
BETHLEHEM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18017-8917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-954-4210
Provider Business Practice Location Address Fax Number:
610-882-0246
Provider Enumeration Date:
03/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BORGIONI
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY ADMINISTRATOR
Authorized Official Telephone Number:
484-526-7650

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  FH0725412 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 1000002573 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: PP-481788 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251F00000X , with the licence number: PP-481788 , 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: 1021941790003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 213649 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 6112210002 . This is a "MEDICARE NHIC PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 39HA15 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 121601 . This is a "THREE RIVERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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