Provider Demographics
NPI:1952302960
Name:KOPP DRUG 58TH ST. INC.
Entity Type:Organization
Organization Name:KOPP DRUG 58TH ST. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:BARNEST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-949-9512
Mailing Address - Street 1:PO BOX 1471
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16603-1471
Mailing Address - Country:US
Mailing Address - Phone:814-949-9512
Mailing Address - Fax:814-949-9505
Practice Address - Street 1:5800 6TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-1113
Practice Address - Country:US
Practice Address - Phone:814-949-3988
Practice Address - Fax:814-949-0906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP-481119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019059780002Medicaid
PA4384520001Medicare NSC