Basic Information
| Provider Information | |||||||||
| NPI: | 1952623274 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EPHRATA COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WELLSPAN CANCER CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 169 MARTIN AVENUE | ||||||||
| Address2: | |||||||||
| City: | EPHRATA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175221002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177382517 | ||||||||
| FaxNumber: | 7177339442 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 MARTIN AVENUE | ||||||||
| Address2: | |||||||||
| City: | EPHRATA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175221002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177382517 | ||||||||
| FaxNumber: | 7177339442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2010 | ||||||||
| LastUpdateDate: | 03/15/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLETTS | ||||||||
| AuthorizedOfficialFirstName: | CARRIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7177382517 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EPHRATA COMMUNITY HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336I0012X | N | Suppliers | Pharmacy | Institutional Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336C0003X | PP481118 | PA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 3993373 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 3993373 | 01 | PA | NCPDP PROVIDER ID | OTHER |