Provider Demographics
NPI:1932145950
Name:SHADY MAPLE PHARMACY
Entity Type:Organization
Organization Name:SHADY MAPLE PHARMACY
Other - Org Name:SHADY MAPLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MGR
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:717-355-9424
Mailing Address - Street 1:PO BOX 137
Mailing Address - Street 2:
Mailing Address - City:EAST EARL
Mailing Address - State:PA
Mailing Address - Zip Code:17519-0137
Mailing Address - Country:US
Mailing Address - Phone:717-355-9424
Mailing Address - Fax:717-351-0253
Practice Address - Street 1:1324 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST EARL
Practice Address - State:PA
Practice Address - Zip Code:17519-9508
Practice Address - Country:US
Practice Address - Phone:717-355-9424
Practice Address - Fax:717-351-0253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4815123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2087490OtherPK
PA1014656950001Medicaid