Provider Demographics
NPI:1215034152
Name:COUNTY LINE PHARMACY INC
Entity Type:Organization
Organization Name:COUNTY LINE PHARMACY INC
Other - Org Name:COUNTY LINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:EVES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:210-260-8662
Mailing Address - Street 1:25 S YORK RD
Mailing Address - Street 2:
Mailing Address - City:HATBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19040-3231
Mailing Address - Country:US
Mailing Address - Phone:215-443-7700
Mailing Address - Fax:215-443-8255
Practice Address - Street 1:25 S YORK RD
Practice Address - Street 2:
Practice Address - City:HATBORO
Practice Address - State:PA
Practice Address - Zip Code:19040-3231
Practice Address - Country:US
Practice Address - Phone:215-443-7700
Practice Address - Fax:215-443-8255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336I0012X
PAPP4813173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3982522OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PA5106220001Medicare NSC