Provider Demographics
NPI:1467441204
Name:MPA PHARMACEUTICAL SERVICES LLC
Entity Type:Organization
Organization Name:MPA PHARMACEUTICAL SERVICES LLC
Other - Org Name:FAIRWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-278-8790
Mailing Address - Street 1:16750 SR 706
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MONTROSE
Mailing Address - State:PA
Mailing Address - Zip Code:18801-9263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16750 SR 706
Practice Address - Street 2:SUITE 5
Practice Address - City:MONTROSE
Practice Address - State:PA
Practice Address - Zip Code:18801-9263
Practice Address - Country:US
Practice Address - Phone:570-278-8790
Practice Address - Fax:570-278-2975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PAPP415788L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
3979347OtherOTHER ID NUMBER
OH2253850Medicaid
PA1857781Medicaid
OH2253850Medicaid