Provider Demographics
NPI:1609401926
Name:BLUEBERRY PHARMACY
Entity Type:Organization
Organization Name:BLUEBERRY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:412-612-2279
Mailing Address - Street 1:9080 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15237-4528
Mailing Address - Country:US
Mailing Address - Phone:814-521-1655
Mailing Address - Fax:
Practice Address - Street 1:1018 W VIEW PARK DR
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15229-1771
Practice Address - Country:US
Practice Address - Phone:412-612-2279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-06
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPP482949OtherBOARD OF PHARMACY PERMIT