Provider Demographics
NPI:1710995071
Name:DUBOIS REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:DUBOIS REGIONAL MEDICAL CENTER
Other - Org Name:BROCKWAY DRUG CO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF RETAIL PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-299-7553
Mailing Address - Street 1:1365 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15824-1635
Mailing Address - Country:US
Mailing Address - Phone:814-268-3305
Mailing Address - Fax:814-265-1143
Practice Address - Street 1:1365 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:PA
Practice Address - Zip Code:15824-1635
Practice Address - Country:US
Practice Address - Phone:814-268-3305
Practice Address - Fax:814-265-1143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410257L332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006339800002Medicaid
3915482OtherNABP NUMBER
0732630001Medicare NSC