Provider Demographics
NPI:1659318582
Name:BSDS, INC.
Entity Type:Organization
Organization Name:BSDS, INC.
Other - Org Name:BAUSE'S SUPER DRUG STORE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MELLOTT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:610-367-8641
Mailing Address - Street 1:42 E PHILADELPHIA AVE
Mailing Address - Street 2:
Mailing Address - City:BOYERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19512-1125
Mailing Address - Country:US
Mailing Address - Phone:610-367-8641
Mailing Address - Fax:610-369-0945
Practice Address - Street 1:42 E PHILADELPHIA AVE
Practice Address - Street 2:
Practice Address - City:BOYERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19512-1125
Practice Address - Country:US
Practice Address - Phone:610-367-8641
Practice Address - Fax:610-369-0945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410131L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3960413OtherNABP
PA001210316-0001Medicaid
PA4491340001Medicare ID - Type UnspecifiedMEDICARE