Provider Demographics
NPI:1083715635
Name:HERITAGE VALLEY PHARMACY @ BEAVER CAMPUS
Entity Type:Organization
Organization Name:HERITAGE VALLEY PHARMACY @ BEAVER CAMPUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRUM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-773-7777
Mailing Address - Street 1:6740 NW MONOCO CT
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-5341
Mailing Address - Country:US
Mailing Address - Phone:772-643-6331
Mailing Address - Fax:
Practice Address - Street 1:1000 DUTCH RIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9727
Practice Address - Country:US
Practice Address - Phone:724-773-7777
Practice Address - Fax:724-773-2912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4813043336C0003X
PA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000033550213Medicaid
PA1000033550194Medicaid
PA3982510OtherNCPDP NUMBER
PA1000033550213Medicaid