Provider Demographics
NPI:1689785370
Name:PORT AQLLEGANY PHARMACY
Entity Type:Organization
Organization Name:PORT AQLLEGANY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:FARBER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-642-2871
Mailing Address - Street 1:54 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEGANY
Mailing Address - State:PA
Mailing Address - Zip Code:16743-1337
Mailing Address - Country:US
Mailing Address - Phone:814-642-2871
Mailing Address - Fax:814-642-7724
Practice Address - Street 1:54 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT ALLEGANY
Practice Address - State:PA
Practice Address - Zip Code:16743-1337
Practice Address - Country:US
Practice Address - Phone:814-642-2871
Practice Address - Fax:814-642-7724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP025802L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty