1699912543 NPI number — PUNXSY HOMETOWN PHARMACY LLC

Table of content: JEFFREY SABA MOON PHARM.D (NPI 1124311659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699912543 NPI number — PUNXSY HOMETOWN PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUNXSY HOMETOWN PHARMACY 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:
1699912543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 HAMPTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUNXSUTAWNEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15767-2133
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:
203 HAMPTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUNXSUTAWNEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15767-2133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-938-9150
Provider Business Practice Location Address Fax Number:
814-938-9151
Provider Enumeration Date:
01/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KERNICH
Authorized Official First Name:
NICKOLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER/OWNER
Authorized Official Telephone Number:
814-591-7125

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: PP481900 , 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: 1022626600001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3991773 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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