Provider Demographics
NPI:1609219179
Name:LINESVILLE PHARMACY INC
Entity Type:Organization
Organization Name:LINESVILLE PHARMACY INC
Other - Org Name:LINESVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRETTON
Authorized Official - Middle Name:
Authorized Official - Last Name:WALBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-612-2131
Mailing Address - Street 1:343 MERCER RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-9773
Mailing Address - Country:US
Mailing Address - Phone:724-885-0310
Mailing Address - Fax:330-876-0195
Practice Address - Street 1:123 W ERIE ST
Practice Address - Street 2:
Practice Address - City:LINESVILLE
Practice Address - State:PA
Practice Address - Zip Code:16424-9227
Practice Address - Country:US
Practice Address - Phone:814-818-0010
Practice Address - Fax:814-818-0024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-15
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4823753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138478OtherPK
PA1029111950001Medicaid