Provider Demographics
NPI:1023361631
Name:MINERSVILLE PHARMACY, INC.
Entity Type:Organization
Organization Name:MINERSVILLE PHARMACY, INC.
Other - Org Name:MINERSVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSHWARRA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-399-5488
Mailing Address - Street 1:106 SUNBURY ST
Mailing Address - Street 2:
Mailing Address - City:MINERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17954-1443
Mailing Address - Country:US
Mailing Address - Phone:570-399-5488
Mailing Address - Fax:570-399-5490
Practice Address - Street 1:106 SUNBURY ST
Practice Address - Street 2:
Practice Address - City:MINERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17954-1443
Practice Address - Country:US
Practice Address - Phone:570-399-5488
Practice Address - Fax:570-399-5490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4823143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPP482314OtherSTATE PHARMACY PERMIT