Provider Demographics
NPI:1699845354
Name:SRI GANESH PHARMACY OF HYNDMAN INC
Entity Type:Organization
Organization Name:SRI GANESH PHARMACY OF HYNDMAN INC
Other - Org Name:POTOMAC VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TEJAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-842-3201
Mailing Address - Street 1:PO BOX 694
Mailing Address - Street 2:138 WASHINGTON ST
Mailing Address - City:HYNDMAN
Mailing Address - State:PA
Mailing Address - Zip Code:15545
Mailing Address - Country:US
Mailing Address - Phone:814-842-3201
Mailing Address - Fax:814-842-3711
Practice Address - Street 1:138 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HYNDMAN
Practice Address - State:PA
Practice Address - Zip Code:15545
Practice Address - Country:US
Practice Address - Phone:814-842-3201
Practice Address - Fax:814-842-3711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PAPP411775L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD002202101Medicaid
PA1007630390003Medicaid
PA1007630390003Medicaid