Provider Demographics
NPI:1720358344
Name:DEPIETROS PHARMACY LLC
Entity Type:Organization
Organization Name:DEPIETROS PHARMACY LLC
Other - Org Name:DEPIETROS PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPIETRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-209-7440
Mailing Address - Street 1:617 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-2849
Mailing Address - Country:US
Mailing Address - Phone:570-209-7440
Mailing Address - Fax:570-209-7442
Practice Address - Street 1:617 3RD ST
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-2849
Practice Address - Country:US
Practice Address - Phone:570-209-7440
Practice Address - Fax:570-209-7442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4822353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3996646OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3996646OtherNCPDP PROVIDER IDENTIFICATION NUMBER