1669823266 NPI number — PERIGON PHARMACY 360, LLC

Table of content: (NPI 1669823266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669823266 NPI number — PERIGON PHARMACY 360, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERIGON PHARMACY 360, 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:
1669823266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 STEVENSON MILL RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAOPOLIS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15108-2446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-698-2533
Provider Business Mailing Address Fax Number:
844-582-5332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 STEVENSON MILL RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORAOPOLIS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15108-2446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-684-2500
Provider Business Practice Location Address Fax Number:
844-582-5332
Provider Enumeration Date:
06/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRICKSON
Authorized Official First Name:
GENESE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
412-684-2500

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1032363790001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1669823266 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1689851 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7P2679 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 564121700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2111445 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2160783 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 656739 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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