Provider Demographics
NPI:1013916170
Name:TRI-VALLEY PHARMACY, INCORPORATED
Entity Type:Organization
Organization Name:TRI-VALLEY PHARMACY, INCORPORATED
Other - Org Name:TRI-VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-345-4966
Mailing Address - Street 1:101 S TULPEHOCKEN ST
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17963-1011
Mailing Address - Country:US
Mailing Address - Phone:570-345-4966
Mailing Address - Fax:
Practice Address - Street 1:101 S TULPEHOCKEN ST
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:PA
Practice Address - Zip Code:17963-1011
Practice Address - Country:US
Practice Address - Phone:570-345-4966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PAPP415649L333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007504240005Medicaid
1046720003Medicare NSC