Provider Demographics
NPI:1609223197
Name:BRUNDAGE PHARMACIES INC.
Entity Type:Organization
Organization Name:BRUNDAGE PHARMACIES INC.
Other - Org Name:BRUNDAGE'S LAKE REGION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNDAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-488-7979
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:WAYMART
Mailing Address - State:PA
Mailing Address - Zip Code:18472-0398
Mailing Address - Country:US
Mailing Address - Phone:570-488-7979
Mailing Address - Fax:570-488-7773
Practice Address - Street 1:2489 ROUTE 6
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:PA
Practice Address - Zip Code:18428-6078
Practice Address - Country:US
Practice Address - Phone:570-390-7655
Practice Address - Fax:570-390-7657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP482647333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160099OtherPK