Provider Demographics
NPI:1750470308
Name:LORDS VALLEY VILLAGE PHARMACY INC
Entity Type:Organization
Organization Name:LORDS VALLEY VILLAGE PHARMACY INC
Other - Org Name:LORDS VALLEY VILLAGE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-499-1900
Mailing Address - Street 1:658 ROUTE 739
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HAWLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18428-6086
Mailing Address - Country:US
Mailing Address - Phone:570-775-9555
Mailing Address - Fax:570-775-9593
Practice Address - Street 1:658 ROUTE 739
Practice Address - Street 2:SUITE 5
Practice Address - City:HAWLEY
Practice Address - State:PA
Practice Address - Zip Code:18428-6086
Practice Address - Country:US
Practice Address - Phone:570-775-9555
Practice Address - Fax:570-775-9593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP414053L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2086573OtherPK
PA001126769-0003Medicaid
2086573OtherPK