Provider Demographics
NPI:1275616625
Name:BURRELL PHARMACY, INC
Entity Type:Organization
Organization Name:BURRELL PHARMACY, INC
Other - Org Name:BURRELL HEALTHMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MICKLOW
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-334-1067
Mailing Address - Street 1:2889 LEECHBURG RD
Mailing Address - Street 2:
Mailing Address - City:LOWER BURRELL
Mailing Address - State:PA
Mailing Address - Zip Code:15068-2542
Mailing Address - Country:US
Mailing Address - Phone:724-334-1067
Mailing Address - Fax:724-334-9681
Practice Address - Street 1:2889 LEECHBURG RD
Practice Address - Street 2:
Practice Address - City:LOWER BURRELL
Practice Address - State:PA
Practice Address - Zip Code:15068-2542
Practice Address - Country:US
Practice Address - Phone:724-334-1067
Practice Address - Fax:724-334-9681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4812883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3982483OtherNCPDP
PA0019711310001Medicaid
PA5286310001Medicare ID - Type Unspecified