Provider Demographics
NPI:1104847169
Name:ROBERT PACKER HOSPITAL
Entity Type:Organization
Organization Name:ROBERT PACKER HOSPITAL
Other - Org Name:CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-887-2816
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:SUITE EC101
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-887-2800
Mailing Address - Fax:570-887-2827
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:SUITE EC101
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-887-2800
Practice Address - Fax:570-887-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP413232L3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1161970002OtherMEDICARE PTAN
PA1007706140042Medicaid
2082808OtherPK