Provider Demographics
NPI:1407899693
Name:PROFESSIONAL SPECIALIZED PHARMACIES LLC
Entity Type:Organization
Organization Name:PROFESSIONAL SPECIALIZED PHARMACIES LLC
Other - Org Name:HOMETOWN PHARMACY 03
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:NAIRN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:412-921-7731
Mailing Address - Street 1:2362 GOLDEN MILE HWY
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15239-2710
Mailing Address - Country:US
Mailing Address - Phone:724-387-2260
Mailing Address - Fax:724-387-2261
Practice Address - Street 1:2362 GOLDEN MILE HWY
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15239-2710
Practice Address - Country:US
Practice Address - Phone:724-387-2260
Practice Address - Fax:724-387-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP481378183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100748860014Medicaid
PA100748860014Medicaid
PA127453007Medicare ID - Type Unspecified