Provider Demographics
NPI:1760481923
Name:TRI-VALLEY PHARMACY, INC.
Entity Type:Organization
Organization Name:TRI-VALLEY PHARMACY, INC.
Other - Org Name:TRI-VALLEY PHARMACY #1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-695-3120
Mailing Address - Street 1:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:VALLEY VIEW
Mailing Address - State:PA
Mailing Address - Zip Code:17983-0186
Mailing Address - Country:US
Mailing Address - Phone:570-695-3120
Mailing Address - Fax:
Practice Address - Street 1:7 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TREMONT
Practice Address - State:PA
Practice Address - Zip Code:17981-1707
Practice Address - Country:US
Practice Address - Phone:570-695-3120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP414494-L333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007504240004Medicaid
1046720002Medicare NSC