1457690026 NPI number — LUXBURY VENTURES LLC

Table of content: (NPI 1457690026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457690026 NPI number — LUXBURY VENTURES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUXBURY VENTURES 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:
OAKSIDE CARE PHARMACY
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:
1457690026
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
422 AUGUSTA DR E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
READING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19608-2128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 LEHIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
READING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19601-1750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-663-5760
Provider Business Practice Location Address Fax Number:
610-378-9000
Provider Enumeration Date:
02/02/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SALAKO
Authorized Official First Name:
FADEKE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
484-663-5760

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: PP482357 , 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: 1028072400001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2140155 . This is a "PK" identifier . This identifiers is of the category "OTHER".