Provider Demographics
NPI:1134652902
Name:POCONO PHARMACY INC
Entity Type:Organization
Organization Name:POCONO PHARMACY INC
Other - Org Name:POCONO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VENUGOPAL
Authorized Official - Middle Name:
Authorized Official - Last Name:NARRAMNENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-421-6789
Mailing Address - Street 1:300 COMMERCE BLVD
Mailing Address - Street 2:SUITE # 130
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360
Mailing Address - Country:US
Mailing Address - Phone:570-421-6789
Mailing Address - Fax:570-421-9992
Practice Address - Street 1:300 COMMERCE BLVD STE 130
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-6215
Practice Address - Country:US
Practice Address - Phone:570-421-6789
Practice Address - Fax:570-421-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4827153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2169385OtherPK
PA1033143120001Medicaid