Provider Demographics
NPI:1326106444
Name:MAINLINE PHARMACY MURRYSVILLE, LLC
Entity Type:Organization
Organization Name:MAINLINE PHARMACY MURRYSVILLE, LLC
Other - Org Name:MAINLINE PHARMACY MURRYSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DECRISCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-408-6800
Mailing Address - Street 1:3907 OLD WILLIAM PENN HWY
Mailing Address - Street 2:
Mailing Address - City:MURRYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15668-1833
Mailing Address - Country:US
Mailing Address - Phone:724-327-6611
Mailing Address - Fax:724-327-5814
Practice Address - Street 1:3907 OLD WILLIAM PENN HWY
Practice Address - Street 2:
Practice Address - City:MURRYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15668-1833
Practice Address - Country:US
Practice Address - Phone:724-327-6611
Practice Address - Fax:724-327-5814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410755L3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103992760-0001Medicaid
2080064OtherPK
2080064OtherPK
0137050001Medicare NSC