Provider Demographics
NPI:1124194881
Name:PHARMACY HEALTH SERVICES INC
Entity Type:Organization
Organization Name:PHARMACY HEALTH SERVICES INC
Other - Org Name:MARBLE WORKS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:802-388-1575
Mailing Address - Street 1:187 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERGENNES
Mailing Address - State:VT
Mailing Address - Zip Code:05491-1117
Mailing Address - Country:US
Mailing Address - Phone:802-877-1190
Mailing Address - Fax:802-877-1197
Practice Address - Street 1:187 MAIN ST
Practice Address - Street 2:
Practice Address - City:VERGENNES
Practice Address - State:VT
Practice Address - Zip Code:05491-1117
Practice Address - Country:US
Practice Address - Phone:802-877-1190
Practice Address - Fax:802-877-1197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 333600000X
VT038.00033993336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1005172Medicaid
2101607OtherPK
0363880002Medicare NSC