Provider Demographics
NPI:1619369840
Name:NELLS FAMILY MARKET OF WALNUT BOTTOM LLC
Entity Type:Organization
Organization Name:NELLS FAMILY MARKET OF WALNUT BOTTOM LLC
Other - Org Name:SHURFINE PHARMACY WALNUT BOTTOM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-324-4924
Mailing Address - Street 1:950 WALNUT BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17015-7636
Mailing Address - Country:US
Mailing Address - Phone:717-243-3468
Mailing Address - Fax:717-243-4610
Practice Address - Street 1:950 WALNUT BOTTOM RD
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17015-7636
Practice Address - Country:US
Practice Address - Phone:717-243-3468
Practice Address - Fax:717-243-4610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP481485L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150484OtherPK