Provider Demographics
NPI:1073835872
Name:JAMES DRUG STORE-PORTAGE LLC
Entity Type:Organization
Organization Name:JAMES DRUG STORE-PORTAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DELLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-886-2266
Mailing Address - Street 1:3692 PORTAGE ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946-6540
Mailing Address - Country:US
Mailing Address - Phone:814-713-8074
Mailing Address - Fax:
Practice Address - Street 1:3692 PORTAGE ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:PA
Practice Address - Zip Code:15946-6540
Practice Address - Country:US
Practice Address - Phone:814-713-8074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-20
Last Update Date:2010-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP481904333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy