Provider Demographics
NPI:1235539800
Name:MAINLINE PHARMACY EBENSBURG, LLC
Entity Type:Organization
Organization Name:MAINLINE PHARMACY EBENSBURG, LLC
Other - Org Name:MAINLINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DECRISCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-408-6800
Mailing Address - Street 1:1049 SHOEMAKER ST STE 1
Mailing Address - Street 2:
Mailing Address - City:NANTY GLO
Mailing Address - State:PA
Mailing Address - Zip Code:15943-1248
Mailing Address - Country:US
Mailing Address - Phone:814-419-6717
Mailing Address - Fax:814-419-6719
Practice Address - Street 1:1049 SHOEMAKER ST STE 1
Practice Address - Street 2:
Practice Address - City:NANTY GLO
Practice Address - State:PA
Practice Address - Zip Code:15943-1248
Practice Address - Country:US
Practice Address - Phone:814-419-6717
Practice Address - Fax:814-419-6719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA333600000X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacyGroup - Multi-Specialty
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102691494-0002Medicaid