Basic Information
| Provider Information | |||||||||
| NPI: | 1053410282 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ECKERD CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RITE AID PHARMACY 11235 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 2460 GEORGE WASHINGTON MEMORIAL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | HAYES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230723566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046422115 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ZOREK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER ONLINE ADJUDICATION | ||||||||
| AuthorizedOfficialTelephone: | 7179755937 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | 201002674 | VA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4830762 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 008510075 | 05 | VA | MEDICAID |