Provider Demographics
NPI:1114096807
Name:EVANS CITY DRUG STORE INC
Entity Type:Organization
Organization Name:EVANS CITY DRUG STORE INC
Other - Org Name:EVANS CITY PHARMACY AND GIFT SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSTOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-538-4240
Mailing Address - Street 1:201 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVANS CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16033-1219
Mailing Address - Country:US
Mailing Address - Phone:724-538-4240
Mailing Address - Fax:724-538-3826
Practice Address - Street 1:201 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EVANS CITY
Practice Address - State:PA
Practice Address - Zip Code:16033-1219
Practice Address - Country:US
Practice Address - Phone:724-538-4240
Practice Address - Fax:724-538-3826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
PAPP412566L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011557890001Medicaid
2087018OtherPK
PA0011557890001Medicaid
PA0398900001Medicare NSC