Provider Demographics
NPI:1114099777
Name:COSTA, JOSEPH J (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:J
Last Name:COSTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 OLD STATE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9430
Mailing Address - Country:US
Mailing Address - Phone:570-587-5682
Mailing Address - Fax:
Practice Address - Street 1:800 MAIN ST
Practice Address - Street 2:
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1546
Practice Address - Country:US
Practice Address - Phone:570-489-5161
Practice Address - Fax:570-307-0730
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP029809L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP029809LOtherSTATE LICENSE NUMBER