Provider Demographics
NPI:1851780795
Name:PENNTRUST MEDICAL HOLDINGS LLC
Entity Type:Organization
Organization Name:PENNTRUST MEDICAL HOLDINGS LLC
Other - Org Name:YARDLEY PHARMACY & SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:267-532-7073
Mailing Address - Street 1:175 S MAIN ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-1623
Mailing Address - Country:US
Mailing Address - Phone:267-573-4555
Mailing Address - Fax:267-573-4966
Practice Address - Street 1:175 S MAIN ST
Practice Address - Street 2:UNIT 2
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-1623
Practice Address - Country:US
Practice Address - Phone:267-573-4555
Practice Address - Fax:267-573-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-15
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4825373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7408530001Medicare NSC