Provider Demographics
NPI:1851340350
Name:STATE OF DELAWARE
Entity Type:Organization
Organization Name:STATE OF DELAWARE
Other - Org Name:DE HOSPITAL FOR THE CHRONICALLY ILL-PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:HOSPITAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BARNABAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KERKULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-223-1200
Mailing Address - Street 1:100 SUNNYSIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:DE
Mailing Address - Zip Code:19977-1752
Mailing Address - Country:US
Mailing Address - Phone:302-223-1373
Mailing Address - Fax:
Practice Address - Street 1:100 SUNNYSIDE ROAD
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1752
Practice Address - Country:US
Practice Address - Phone:302-223-1373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-11-02
Deactivation Date:2012-02-22
Deactivation Code:
Reactivation Date:2013-07-03
Provider Licenses
StateLicense IDTaxonomies
DEA300006913336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE00001210149Medicaid
DE0000121049Medicaid