Provider Demographics
NPI:1023007275
Name:FRIENDSVILLE PHARMACY UPHOLD LLC
Entity Type:Organization
Organization Name:FRIENDSVILLE PHARMACY UPHOLD LLC
Other - Org Name:FRIENDSVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMD
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:UPHOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-483-4310
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:FRIENDSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21531-0127
Mailing Address - Country:US
Mailing Address - Phone:301-746-5881
Mailing Address - Fax:301-746-5803
Practice Address - Street 1:248 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FRIENDSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21531-2122
Practice Address - Country:US
Practice Address - Phone:301-746-5881
Practice Address - Fax:301-746-5803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP06419333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146948OtherPK
MD3810028824Medicaid