Provider Demographics
NPI:1528413804
Name:YANKEETOWN GOLDEN SPIKE
Entity Type:Organization
Organization Name:YANKEETOWN GOLDEN SPIKE
Other - Org Name:YANKEETOWN APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNKLE
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MS, PHARMD
Authorized Official - Phone:724-471-7471
Mailing Address - Street 1:60 YANKEETOWN AVE
Mailing Address - Street 2:
Mailing Address - City:HOMER CITY
Mailing Address - State:PA
Mailing Address - Zip Code:15748-1011
Mailing Address - Country:US
Mailing Address - Phone:724-471-7471
Mailing Address - Fax:724-471-0262
Practice Address - Street 1:60 YANKEETOWN AVE
Practice Address - Street 2:
Practice Address - City:HOMER CITY
Practice Address - State:PA
Practice Address - Zip Code:15748-1011
Practice Address - Country:US
Practice Address - Phone:724-471-7471
Practice Address - Fax:724-471-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
PAPP4826603336M0002X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103133765Medicaid
2160615OtherPK