Provider Demographics
NPI:1770676959
Name:JOHN R SLAGLE
Entity Type:Organization
Organization Name:JOHN R SLAGLE
Other - Org Name:TIONESTA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SLAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-782-6215
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:TIONESTA
Mailing Address - State:PA
Mailing Address - Zip Code:16353-0340
Mailing Address - Country:US
Mailing Address - Phone:814-755-3557
Mailing Address - Fax:814-755-3648
Practice Address - Street 1:105 FAULKNER DRIVE
Practice Address - Street 2:
Practice Address - City:TIONESTA
Practice Address - State:PA
Practice Address - Zip Code:16353
Practice Address - Country:US
Practice Address - Phone:814-755-3557
Practice Address - Fax:814-755-3648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP413809L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007724210004Medicaid
2085419OtherPK
2085419OtherPK