Provider Demographics
NPI:1922247097
Name:MAIN STREET DRUG STORE INC
Entity Type:Organization
Organization Name:MAIN STREET DRUG STORE INC
Other - Org Name:EVERETT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISEMINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-652-5532
Mailing Address - Street 1:108 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-1258
Mailing Address - Country:US
Mailing Address - Phone:814-652-5532
Mailing Address - Fax:814-652-2927
Practice Address - Street 1:108 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-1258
Practice Address - Country:US
Practice Address - Phone:814-652-5532
Practice Address - Fax:814-652-2927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
PAPP410712L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022770360001Medicaid
3991761OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PA559319Medicaid