Provider Demographics
NPI:1114393790
Name:MILLCREEK MANOR PHARMACY
Entity Type:Organization
Organization Name:MILLCREEK MANOR PHARMACY
Other - Org Name:LECOM SENIOR LIVING CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:BABIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-868-3880
Mailing Address - Street 1:5535 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2603
Mailing Address - Country:US
Mailing Address - Phone:814-868-3869
Mailing Address - Fax:814-868-3405
Practice Address - Street 1:5535 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2603
Practice Address - Country:US
Practice Address - Phone:814-868-3869
Practice Address - Fax:814-868-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
PAPP4825693336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151152OtherPK