Provider Demographics
NPI:1891867966
Name:COSTA DRUGS INC
Entity Type:Organization
Organization Name:COSTA DRUGS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:CELLERARI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-587-4717
Mailing Address - Street 1:100 OLD LACKAWANNA TRL
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9108
Mailing Address - Country:US
Mailing Address - Phone:570-587-4717
Mailing Address - Fax:570-587-2619
Practice Address - Street 1:100 OLD LACKAWANNA TRL
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-9108
Practice Address - Country:US
Practice Address - Phone:570-587-4717
Practice Address - Fax:570-587-2619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410982L332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3938721OtherNCPDP NUMBER
PA0005826490002Medicaid
PA0393872OtherPACE PROVIDER NUMBER
PA0005826490002Medicaid