Provider Demographics
NPI:1205837879
Name:BLACKBURNS PHYSICIANS PHARMACY INC
Entity Type:Organization
Organization Name:BLACKBURNS PHYSICIANS PHARMACY INC
Other - Org Name:BLACKBURNS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUKAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-224-9100
Mailing Address - Street 1:301 CORBET ST
Mailing Address - Street 2:
Mailing Address - City:TARENTUM
Mailing Address - State:PA
Mailing Address - Zip Code:15084-1877
Mailing Address - Country:US
Mailing Address - Phone:724-224-9100
Mailing Address - Fax:724-224-6108
Practice Address - Street 1:301 CORBET ST
Practice Address - Street 2:
Practice Address - City:TARENTUM
Practice Address - State:PA
Practice Address - Zip Code:15084-1877
Practice Address - Country:US
Practice Address - Phone:724-224-9100
Practice Address - Fax:724-224-6108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PAPP411868L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005581420001Medicaid
PA0005581420001Medicaid