Provider Demographics
NPI:1598771263
Name:3JB LLC
Entity Type:Organization
Organization Name:3JB LLC
Other - Org Name:MAINLINE PHARMACY - SOMERSET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DECRISCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-408-6800
Mailing Address - Street 1:168 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-2038
Mailing Address - Country:US
Mailing Address - Phone:814-445-6511
Mailing Address - Fax:814-445-5908
Practice Address - Street 1:168 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-2038
Practice Address - Country:US
Practice Address - Phone:814-445-6511
Practice Address - Fax:814-445-5908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP412340L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103037188-0002Medicaid
3900164OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3900164OtherNCPDP PROVIDER IDENTIFICATION NUMBER