Provider Demographics
NPI:1972615490
Name:CHARLES F TRAEGER
Entity Type:Organization
Organization Name:CHARLES F TRAEGER
Other - Org Name:AYRES DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:412-672-3000
Mailing Address - Street 1:3000 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MCKEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15132-7158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 WALNUT ST
Practice Address - Street 2:
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15132-7158
Practice Address - Country:US
Practice Address - Phone:412-672-3000
Practice Address - Fax:412-672-8983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410097L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3919543OtherOTHER ID NUMBER
PA000568505Medicaid