Provider Demographics
NPI:1669823266
Name:PERIGON PHARMACY 360, LLC
Entity Type:Organization
Organization Name:PERIGON PHARMACY 360, LLC
Other - Org Name:VALEDA RX LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GENESE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-684-2500
Mailing Address - Street 1:1120 STEVENSON MILL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CORAOPOLIS
Mailing Address - State:PA
Mailing Address - Zip Code:15108-2446
Mailing Address - Country:US
Mailing Address - Phone:844-698-2533
Mailing Address - Fax:844-582-5332
Practice Address - Street 1:1120 STEVENSON MILL RD STE 200
Practice Address - Street 2:
Practice Address - City:CORAOPOLIS
Practice Address - State:PA
Practice Address - Zip Code:15108-2446
Practice Address - Country:US
Practice Address - Phone:412-684-2500
Practice Address - Fax:844-582-5332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-24
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032363790001Medicaid
CO1669823266Medicaid
AK1689851Medicaid
SC7P2679Medicaid
MD564121700Medicaid
WA2111445Medicaid
2160783OtherPK
NJ656739Medicaid
MD564121700Medicaid
2160783OtherPK