Provider Demographics
NPI:1417977984
Name:COSTA'S APOTHECARY, INC
Entity Type:Organization
Organization Name:COSTA'S APOTHECARY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:AMORUSO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:610-521-1000
Mailing Address - Street 1:113 E SELLERS AVE
Mailing Address - Street 2:
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-2307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 E SELLERS AVE
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-2307
Practice Address - Country:US
Practice Address - Phone:610-521-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP025305L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1617981Medicaid
PA1617981Medicaid