Provider Demographics
NPI:1689694283
Name:ENDLESS MOUNTAINS PHARMACY INC
Entity Type:Organization
Organization Name:ENDLESS MOUNTAINS PHARMACY INC
Other - Org Name:ENDLESS MOUNTAINS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:570-222-7500
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:CLIFFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18413-0189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1638 STATE ROUTE 106
Practice Address - Street 2:
Practice Address - City:CLIFFORD
Practice Address - State:PA
Practice Address - Zip Code:18413
Practice Address - Country:US
Practice Address - Phone:570-222-7500
Practice Address - Fax:570-222-7503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4811273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018873230002Medicaid
2085895OtherPK
PA0018873230002Medicaid