Provider Demographics
NPI:1508889858
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
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:814-387-4014
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:
Mailing Address - Fax:
Practice Address - Street 1:402 E SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:SNOW SHOE
Practice Address - State:PA
Practice Address - Zip Code:16874-8832
Practice Address - Country:US
Practice Address - Phone:814-387-4014
Practice Address - Fax:814-387-6934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP412361L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2085757OtherPK
PA1007479930009Medicaid
2085757OtherPK