Provider Demographics
NPI:1124393970
Name:FAMILY PHARMACY OF MOSCOW INC
Entity Type:Organization
Organization Name:FAMILY PHARMACY OF MOSCOW INC
Other - Org Name:FAMILY PHARMACY OF MOSCOW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-499-1900
Mailing Address - Street 1:330 N MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MOSCOW
Mailing Address - State:PA
Mailing Address - Zip Code:18444-9003
Mailing Address - Country:US
Mailing Address - Phone:570-843-6369
Mailing Address - Fax:570-843-6351
Practice Address - Street 1:330 N MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:PA
Practice Address - Zip Code:18444-9003
Practice Address - Country:US
Practice Address - Phone:570-843-6369
Practice Address - Fax:570-843-6351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4822503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3996975OtherNCPDP PROVIDER IDENTIFICATION NUMBER