Provider Demographics
NPI:1790790392
Name:SULCO RX, LLC
Entity Type:Organization
Organization Name:SULCO RX, LLC
Other - Org Name:DUSHORE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-244-8674
Mailing Address - Street 1:PO BOX 314
Mailing Address - Street 2:
Mailing Address - City:DUSHORE
Mailing Address - State:PA
Mailing Address - Zip Code:18614-0314
Mailing Address - Country:US
Mailing Address - Phone:570-928-8010
Mailing Address - Fax:570-928-7036
Practice Address - Street 1:220 S GERMAN ST
Practice Address - Street 2:
Practice Address - City:DUSHORE
Practice Address - State:PA
Practice Address - Zip Code:18614-7891
Practice Address - Country:US
Practice Address - Phone:570-928-8010
Practice Address - Fax:570-928-7036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP413412L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012953870001Medicaid
2081283OtherPK
1044570001Medicare NSC