Provider Demographics
NPI:1255509667
Name:SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET PHARMACY
Entity Type:Organization
Organization Name:SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SIMODEJKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-621-5111
Mailing Address - Street 1:700 E NORWEGIAN ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-2710
Mailing Address - Country:US
Mailing Address - Phone:570-621-5111
Mailing Address - Fax:
Practice Address - Street 1:700 E NORWEGIAN ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2710
Practice Address - Country:US
Practice Address - Phone:570-621-5111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-19
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAHP418077L333600000X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA390031Medicare PIN