Provider Demographics
NPI:1386041655
Name:MOMBA PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:MOMBA PHARMACY SERVICES LLC
Other - Org Name:WALTMIRE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPASQUALE
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPASQUALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-559-5082
Mailing Address - Street 1:1435 SPRING GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-3711
Mailing Address - Country:US
Mailing Address - Phone:412-323-1801
Mailing Address - Fax:412-323-1687
Practice Address - Street 1:1435 SPRING GARDEN AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-3711
Practice Address - Country:US
Practice Address - Phone:412-323-1801
Practice Address - Fax:412-323-1687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP411539L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102673880Medicaid
2149578OtherPK