Provider Demographics
NPI:1619005782
Name:JEANNETTE E. DRAHUSCHAK
Entity Type:Organization
Organization Name:JEANNETTE E. DRAHUSCHAK
Other - Org Name:GROVE CITY OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DRAHUSCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:724-458-8533
Mailing Address - Street 1:808 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-1114
Mailing Address - Country:US
Mailing Address - Phone:724-458-8533
Mailing Address - Fax:724-458-0911
Practice Address - Street 1:808 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-1114
Practice Address - Country:US
Practice Address - Phone:724-458-8533
Practice Address - Fax:724-458-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000000009251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014304750001Medicaid
PAGR285062OtherBLUE CROSS
PA0779630001OtherMEDICARE DME
PAGR285062OtherBLUE CROSS