Provider Demographics
NPI:1922160548
Name:PALMER PHARMACY LLC
Entity Type:Organization
Organization Name:PALMER PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAITLYN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:724-265-1632
Mailing Address - Street 1:738 LITTLE DEER CREEK VALLEY ROAD PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:RUSSELLTON
Mailing Address - State:PA
Mailing Address - Zip Code:15076-0029
Mailing Address - Country:US
Mailing Address - Phone:724-265-1632
Mailing Address - Fax:724-265-1120
Practice Address - Street 1:738 LITTLE DEER CREEK VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:RUSSELLTON
Practice Address - State:PA
Practice Address - Zip Code:15076-0029
Practice Address - Country:US
Practice Address - Phone:724-265-1632
Practice Address - Fax:724-265-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP411760L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2082069OtherPK
PA1036260510001Medicaid
2082069OtherPK