Provider Demographics
NPI:1487687653
Name:NORTHERN ADVENTURES INC.
Entity Type:Organization
Organization Name:NORTHERN ADVENTURES INC.
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HAYLETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:81433-788-8025
Mailing Address - Street 1:629 STATE ST
Mailing Address - Street 2:PO BOX 805
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2262
Mailing Address - Country:US
Mailing Address - Phone:814-337-8880
Mailing Address - Fax:814-333-4197
Practice Address - Street 1:629 STATE ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2262
Practice Address - Country:US
Practice Address - Phone:814-337-8880
Practice Address - Fax:814-333-4197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP413389L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022544990001Medicaid
PA3935650OtherNCPDP #
PABT6770932OtherDEA #
PA124139Medicare PIN
PA3935650OtherNCPDP #