Provider Demographics
NPI:1477556363
Name:SOVEREIGN COVENANT PHARMACY LLC
Entity Type:Organization
Organization Name:SOVEREIGN COVENANT PHARMACY LLC
Other - Org Name:CARL'S DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:717-597-2426
Mailing Address - Street 1:145 N ANTRIM WAY
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:17225-1403
Mailing Address - Country:US
Mailing Address - Phone:717-597-2426
Mailing Address - Fax:717-597-3705
Practice Address - Street 1:145 N ANTRIM WAY
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:PA
Practice Address - Zip Code:17225-1403
Practice Address - Country:US
Practice Address - Phone:717-597-2426
Practice Address - Fax:717-597-3705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410348L332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001889589001Medicaid
PA3914137OtherNCPDP NUMBER
PA3914137OtherNCPDP NUMBER