Provider Demographics
NPI:1093291023
Name:PASSAVANT DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:PASSAVANT DEVELOPMENT CORPORATION
Other - Org Name:PDC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNKHOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-820-1010
Mailing Address - Street 1:100 PASSAVANT WAY
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 PEACH ST STE 400
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501
Practice Address - Country:US
Practice Address - Phone:814-520-8680
Practice Address - Fax:814-520-6386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-12
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007303880006Medicaid