Basic Information
| Provider Information | |||||||||
| NPI: | 1033209051 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RITE AID OF PENNSYLVANIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 NEWBERRY COMMONS | ||||||||
| Address2: | |||||||||
| City: | ETTERS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173199363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177612633 | ||||||||
| FaxNumber: | 7179758659 | ||||||||
| Practice Location | |||||||||
| Address1: | 4965 CARLISLE PIKE | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179750117 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | ZOREK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7179755937 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | PP415363L | PA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1007292980089 | 05 | PA | MEDICAID | 3973749 | 01 | OTHER ID NUMBER | OTHER | 1007292980089 | 01 | PA | MEDICAID DME | OTHER |