1477643492 NPI number — RITE AID OF PENNSYLVANIA LLC

Table of content: (NPI 1477643492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477643492 NPI number — RITE AID OF PENNSYLVANIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RITE AID OF PENNSYLVANIA 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:
1477643492
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 NEWBERRY COMMONS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ETTERS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17319-9363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-761-2633
Provider Business Mailing Address Fax Number:
717-975-8659

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4641 CHESTNUT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19139-4612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-474-5447
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZOREK
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER ONLINE ADJUDICATION
Authorized Official Telephone Number:
717-975-5937

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PP414902L , 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: 1007292980344 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007292980344 . This is a "MEDICAID DME" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3968306 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".




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