Provider Demographics
NPI:1831102912
Name:JEFFREYS DRUG STORE INC.
Entity Type:Organization
Organization Name:JEFFREYS DRUG STORE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:OHARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-745-6480
Mailing Address - Street 1:1 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-1301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CANONSBURG
Practice Address - State:PA
Practice Address - Zip Code:15317-1301
Practice Address - Country:US
Practice Address - Phone:724-745-6480
Practice Address - Fax:724-745-8818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP411156L332B00000X
333600000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3953228OtherOTHER ID NUMBER
PA1071268Medicaid
5109270001Medicare NSC