1720358344 NPI number — DEPIETROS PHARMACY LLC

Table of content: (NPI 1720358344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720358344 NPI number — DEPIETROS PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPIETROS 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:
1720358344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
617 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUNMORE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18512-2849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-209-7440
Provider Business Mailing Address Fax Number:
570-209-7442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
617 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNMORE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18512-2849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-209-7440
Provider Business Practice Location Address Fax Number:
570-209-7442
Provider Enumeration Date:
01/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DEPIETRO
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER/OWNER
Authorized Official Telephone Number:
570-209-7440

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: PP482235 , 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: 3996646 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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