1053317792 NPI number — BLOOMFIELD PHARMACY INC

Table of content: (NPI 1053317792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053317792 NPI number — BLOOMFIELD PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMFIELD PHARMACY 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:
BLOOMFIELD PHARMACY 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:
1053317792
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 38
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BLOOMFIELD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17068-0038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-582-2313
Provider Business Mailing Address Fax Number:
717-582-4015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BLOOMFIELD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17068-9603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-582-2313
Provider Business Practice Location Address Fax Number:
717-582-4015
Provider Enumeration Date:
06/27/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCCLELLAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRES/RPH/OWNER
Authorized Official Telephone Number:
717-582-2313

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PP410209L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 001225435001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2080269 . This is a "PK" identifier . This identifiers is of the category "OTHER".