Provider Demographics
NPI:1376659748
Name:PLEASANT RIDGE MANOR
Entity Type:Organization
Organization Name:PLEASANT RIDGE MANOR
Other - Org Name:PLEASANT RIDGE MANOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-474-5521
Mailing Address - Street 1:8300 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:PA
Mailing Address - Zip Code:16417-8701
Mailing Address - Country:US
Mailing Address - Phone:814-474-5521
Mailing Address - Fax:814-474-9431
Practice Address - Street 1:8300 RIDGE RD
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:PA
Practice Address - Zip Code:16417-8701
Practice Address - Country:US
Practice Address - Phone:814-474-5521
Practice Address - Fax:814-474-9431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAHP416565L3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007744350006Medicaid
2081200OtherPK
395361Medicare ID - Type Unspecified