Provider Demographics
NPI:1275527814
Name:DUBOIS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:DUBOIS REGIONAL MEDICAL CENTER
Other - Org Name:ST. MARY'S PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SUTIKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-375-3385
Mailing Address - Street 1:4 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-1729
Mailing Address - Country:US
Mailing Address - Phone:814-834-3017
Mailing Address - Fax:814-834-6510
Practice Address - Street 1:4 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-1729
Practice Address - Country:US
Practice Address - Phone:814-834-3017
Practice Address - Fax:814-834-1031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN HIGHLANDS HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-09
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WD0400X, 332BC3200X, 332BN1400X, 332BP3500X, 332BX2000X, 333600000X, 3336C0003X, 3336S0011X, 3336C0003X
PAPP412367L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007711390004Medicaid
2080904OtherPK
2080904OtherPK