Provider Demographics
NPI:1376547265
Name:FORLENZA'S PHARMACY
Entity Type:Organization
Organization Name:FORLENZA'S PHARMACY
Other - Org Name:FORLENZA'S NUTRITIONAL-WELLNESS CENTER AND COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:FORLENZA
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:570-288-6626
Mailing Address - Street 1:531 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18704-2597
Mailing Address - Country:US
Mailing Address - Phone:570-288-6626
Mailing Address - Fax:570-288-9764
Practice Address - Street 1:531 MAIN ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18704-2597
Practice Address - Country:US
Practice Address - Phone:570-288-6626
Practice Address - Fax:570-288-9764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP-411080-L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA24-001095690-0002Medicaid
A08000792OtherSUBMITTER ID#
39-54496OtherNCPDP
PA24001095690-0001Medicaid
PA24001095690-0001Medicaid