Provider Demographics
NPI:1508886433
Name:MOSHANNON VALLEY PHARMACY INC
Entity Type:Organization
Organization Name:MOSHANNON VALLEY PHARMACY INC
Other - Org Name:MOSHANNON VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF PHARMACIES
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANSTETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-342-5200
Mailing Address - Street 1:1605 WASHINGTON AVENUE
Mailing Address - Street 2:PO BOX 529
Mailing Address - City:HYDE
Mailing Address - State:PA
Mailing Address - Zip Code:16843-0529
Mailing Address - Country:US
Mailing Address - Phone:814-765-1800
Mailing Address - Fax:
Practice Address - Street 1:208 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-1948
Practice Address - Country:US
Practice Address - Phone:814-342-5200
Practice Address - Fax:814-342-6749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP413567L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3928770OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PA1007479930001Medicaid
0860100002Medicare NSC