Provider Demographics
NPI:1346330461
Name:RITE AID OF PENNSYLVANIA LLC
Entity Type:Organization
Organization Name:RITE AID OF PENNSYLVANIA LLC
Other - Org Name:RITE AID PHARMACY 01355
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER ONLINE ADJUDICATION
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-975-5937
Mailing Address - Street 1:200 NEWBERRY COMMONS
Mailing Address - Street 2:
Mailing Address - City:ETTERS
Mailing Address - State:PA
Mailing Address - Zip Code:17319-9363
Mailing Address - Country:US
Mailing Address - Phone:717-761-2633
Mailing Address - Fax:717-975-8659
Practice Address - Street 1:504 MARION LANE
Practice Address - Street 2:
Practice Address - City:BRODHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322-0638
Practice Address - Country:US
Practice Address - Phone:570-992-2373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PAPP413424L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007292980388OtherMEDICAID DME
3945550OtherOTHER ID NUMBER
PA1007292980388Medicaid
5455800060Medicare NSC
PA091148Medicare PIN
PA1007292980388Medicaid