Provider Demographics
NPI:1295814978
Name:LANDIS SUPER MARKET INC
Entity Type:Organization
Organization Name:LANDIS SUPER MARKET INC
Other - Org Name:LANDIS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KILLORAN
Authorized Official - Suffix:
Authorized Official - Credentials:BSP
Authorized Official - Phone:717-919-8936
Mailing Address - Street 1:2685 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:TELFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18969-1075
Mailing Address - Country:US
Mailing Address - Phone:877-540-4748
Mailing Address - Fax:801-716-4872
Practice Address - Street 1:2685 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:TELFORD
Practice Address - State:PA
Practice Address - Zip Code:18969-1075
Practice Address - Country:US
Practice Address - Phone:215-723-2302
Practice Address - Fax:215-723-3144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4810833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2085685OtherPK
PA0018678030002Medicaid