Provider Demographics
NPI:1376664755
Name:MED CENTER PHARMACY
Entity Type:Organization
Organization Name:MED CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANG
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IRVIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-684-4212
Mailing Address - Street 1:CLOY AVE EXTENSION
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:PA
Mailing Address - Zip Code:16686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CLOY AVE EXTENSION
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:PA
Practice Address - Zip Code:16686
Practice Address - Country:US
Practice Address - Phone:814-684-4212
Practice Address - Fax:814-684-1410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP411803L333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3939711OtherOTHER ID NUMBER-COMMERCIAL NUMBER
PA0016864230001Medicaid