1003814617 NPI number — PROFESSIONAL SPECIALIZED PHARMACIES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003814617 NPI number — PROFESSIONAL SPECIALIZED PHARMACIES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL SPECIALIZED PHARMACIES 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:
HOMETOWN PHARMACY #2
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:
1003814617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4627 ROUTE 51
Provider Second Line Business Mailing Address:
SUITE 602
Provider Business Mailing Address City Name:
BELLE VERNON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15012-4010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-379-6000
Provider Business Mailing Address Fax Number:
724-379-8548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4627 ROUTE 51
Provider Second Line Business Practice Location Address:
SUITE 602
Provider Business Practice Location Address City Name:
BELLE VERNON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15012-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-379-6000
Provider Business Practice Location Address Fax Number:
724-379-8548
Provider Enumeration Date:
07/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NAIRN
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
DIRECTOR OF RETAIL OPERATIONS
Authorized Official Telephone Number:
412-389-1250

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PP415631L , 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: 100748856 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3977177 . This is a "NABP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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