Provider Demographics
NPI:1417945874
Name:LIGONIER PHARMACY, INC.
Entity Type:Organization
Organization Name:LIGONIER PHARMACY, INC.
Other - Org Name:LIGONIER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NEIDERHISER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-238-6988
Mailing Address - Street 1:113 S FAIRFIELD ST
Mailing Address - Street 2:STE 1
Mailing Address - City:LIGONIER
Mailing Address - State:PA
Mailing Address - Zip Code:15658-1163
Mailing Address - Country:US
Mailing Address - Phone:724-238-6988
Mailing Address - Fax:724-238-7781
Practice Address - Street 1:113 S FAIRFIELD ST
Practice Address - Street 2:STE 1
Practice Address - City:LIGONIER
Practice Address - State:PA
Practice Address - Zip Code:15658-1163
Practice Address - Country:US
Practice Address - Phone:724-238-6988
Practice Address - Fax:724-238-7781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
PAPP413303L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010774950001Medicaid
3951755OtherNCPDP
2085426OtherPK