Provider Demographics
NPI:1306212444
Name:JL SLOCUM LLC
Entity Type:Organization
Organization Name:JL SLOCUM LLC
Other - Org Name:OLD FORGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SLOCUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:570-430-1990
Mailing Address - Street 1:821 S MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1497
Mailing Address - Country:US
Mailing Address - Phone:570-457-3200
Mailing Address - Fax:570-457-3220
Practice Address - Street 1:821 S MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1497
Practice Address - Country:US
Practice Address - Phone:570-457-3200
Practice Address - Fax:570-457-3220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP046173183500000X
PAPP4825773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7457150001Medicare NSC