Provider Demographics
NPI:1770672438
Name:RITE AID OF PENNSYLVANIA LLC
Entity Type:Organization
Organization Name:RITE AID OF PENNSYLVANIA LLC
Other - Org Name:RITE AID PHARMACY 04415
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER ONLINE ADJUDICATION
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-975-5937
Mailing Address - Street 1:200 NEWBERRY COMMONS
Mailing Address - Street 2:
Mailing Address - City:ETTERS
Mailing Address - State:PA
Mailing Address - Zip Code:17319-9363
Mailing Address - Country:US
Mailing Address - Phone:717-761-2633
Mailing Address - Fax:717-975-8659
Practice Address - Street 1:14 FIFTH STREET
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6201
Practice Address - Country:US
Practice Address - Phone:570-321-9350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PAPP415255L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007292981068Medicaid
3972610OtherOTHER ID NUMBER
PA1007292981068OtherMEDICAID DME
0514203161Medicare NSC
3972610OtherOTHER ID NUMBER
PA091148Medicare PIN
PAP00945996Medicare PIN