Provider Demographics
NPI:1659625580
Name:MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA
Entity Type:Organization
Organization Name:MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA
Other - Org Name:MASONIC VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:PRAZENICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-367-1121
Mailing Address - Street 1:99 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-2573
Mailing Address - Country:US
Mailing Address - Phone:717-367-1121
Mailing Address - Fax:717-367-5813
Practice Address - Street 1:1 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-2199
Practice Address - Country:US
Practice Address - Phone:717-367-1121
Practice Address - Fax:717-367-5813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAHP416534L3336I0012X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3998741OtherNCPDP
PAHP416534LOtherPHARMACY LICENSE