Provider Demographics
NPI:1043409212
Name:HEALTHY KIDS RX LLC
Entity Type:Organization
Organization Name:HEALTHY KIDS RX LLC
Other - Org Name:HEALTHY KIDS RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISANTHUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-934-5439
Mailing Address - Street 1:10441 PERRY HWY
Mailing Address - Street 2:STE 16
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9292
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10441 PERRY HWY
Practice Address - Street 2:STE 16
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9292
Practice Address - Country:US
Practice Address - Phone:724-934-5439
Practice Address - Fax:724-934-5442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PAPP4817573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
3989235OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PA1022628480001Medicaid