Basic Information
Provider Information | |||||||||
NPI: | 1013017474 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ECKERD CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RITE AID PHARMACY 11082 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 NEWBERRY COMMONS | ||||||||
Address2: |   | ||||||||
City: | ETTERS | ||||||||
State: | PA | ||||||||
PostalCode: | 173199363 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7177612633 | ||||||||
FaxNumber: | 7179758659 | ||||||||
Practice Location | |||||||||
Address1: | 801 GROW AVENUE | ||||||||
Address2: |   | ||||||||
City: | MONTROSE | ||||||||
State: | PA | ||||||||
PostalCode: | 18801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5702789602 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2006 | ||||||||
LastUpdateDate: | 11/22/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ZOREK | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER ONLINE ADJUDICATION | ||||||||
AuthorizedOfficialTelephone: | 7179755937 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | PP414289L | PA | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 3336C0003X | PP414289L | PA | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 1007308150252 | 01 | PA | MEDICAID DME | OTHER | 3961477 | 01 |   | OTHER ID NUMBER | OTHER | 1007308150261 | 05 | PA |   | MEDICAID |