Provider Demographics
NPI:1063465383
Name:DEBALKOS PHARMACY INC
Entity Type:Organization
Organization Name:DEBALKOS PHARMACY INC
Other - Org Name:STANDARD DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:DEBALKO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH PHARMD
Authorized Official - Phone:570-929-2028
Mailing Address - Street 1:322 S HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:MCADOO
Mailing Address - State:PA
Mailing Address - Zip Code:18237-1608
Mailing Address - Country:US
Mailing Address - Phone:570-929-1130
Mailing Address - Fax:570-929-1208
Practice Address - Street 1:322 S HANCOCK ST
Practice Address - Street 2:
Practice Address - City:MCADOO
Practice Address - State:PA
Practice Address - Zip Code:18237-1608
Practice Address - Country:US
Practice Address - Phone:570-929-1130
Practice Address - Fax:570-929-1208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP412373L332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA237105OtherPA BS DME
PA39HA85OtherCAPITAL BC DME
PA001017817Medicaid
PA237105OtherPA BS DME