Provider Demographics
NPI:1003999053
Name:THE SHEPHERDS HEALTH MART PHARMACY
Entity Type:Organization
Organization Name:THE SHEPHERDS HEALTH MART PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-402-1685
Mailing Address - Street 1:415 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:PA
Mailing Address - Zip Code:18351-0415
Mailing Address - Country:US
Mailing Address - Phone:570-897-7437
Mailing Address - Fax:570-897-2501
Practice Address - Street 1:415 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:PA
Practice Address - Zip Code:18351
Practice Address - Country:US
Practice Address - Phone:570-897-7437
Practice Address - Fax:570-897-2514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4816053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3987318OtherOTHER ID NUMBER-COMMERCIAL NUMBER
PA3987318OtherNABP/NCPDP
PA1017998220001Medicaid
PA5848460001Medicare NSC