Provider Demographics
NPI:1972856151
Name:MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA
Entity Type:Organization
Organization Name:MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FORMICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-367-1121
Mailing Address - Street 1:1 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-2199
Mailing Address - Country:US
Mailing Address - Phone:717-367-1121
Mailing Address - Fax:717-367-5813
Practice Address - Street 1:581 FREEMASON DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-3187
Practice Address - Country:US
Practice Address - Phone:717-367-1121
Practice Address - Fax:717-367-5813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000634A291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
220002197OtherRAILROAD PIN
PA39D0657302OtherCLIA
220002197OtherRAILROAD PIN