Provider Demographics
NPI:1659470920
Name:MAXI DRUG SOUTH LP
Entity Type:Organization
Organization Name:MAXI DRUG SOUTH LP
Other - Org Name:RITE AID PHARMACY 10226
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER ONLINE ADJUDICATION
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-975-5937
Mailing Address - Street 1:200 NEWBERRY COMMONS
Mailing Address - Street 2:
Mailing Address - City:ETTERS
Mailing Address - State:PA
Mailing Address - Zip Code:17319-9363
Mailing Address - Country:US
Mailing Address - Phone:717-761-2633
Mailing Address - Fax:717-975-8659
Practice Address - Street 1:47 VILLAGE PLAZA WAY
Practice Address - Street 2:
Practice Address - City:NORTH SCITUATE
Practice Address - State:RI
Practice Address - Zip Code:02857-1849
Practice Address - Country:US
Practice Address - Phone:401-934-2480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
RIPHA003123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMD16294Medicaid
4105563OtherOTHER ID NUMBER
RI739006369Medicare PIN
4105563OtherOTHER ID NUMBER
RIMD16294Medicaid