Provider Demographics
NPI:1326164138
Name:PENN STATE UHS PHARMACY
Entity Type:Organization
Organization Name:PENN STATE UHS PHARMACY
Other - Org Name:PA UNIVERSITY HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSITANT TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:WIEDEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-865-1355
Mailing Address - Street 1:202C STUDENT HEALTH CENTER
Mailing Address - Street 2:EISENHOWER DRIVE
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:16802
Mailing Address - Country:US
Mailing Address - Phone:814-865-9321
Mailing Address - Fax:814-863-5371
Practice Address - Street 1:202C STUDENT HEALTH CENTER
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PARK
Practice Address - State:PA
Practice Address - Zip Code:16802-2129
Practice Address - Country:US
Practice Address - Phone:814-865-9321
Practice Address - Fax:814-863-5371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAHP418150L3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2080921OtherPK
PA1002707420005Medicaid