Provider Demographics
NPI:1184750580
Name:MEDICINE SHOPPE OF KITTANNING
Entity type:Organization
Organization Name:MEDICINE SHOPPE OF KITTANNING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-545-7350
Mailing Address - Street 1:262 S WATER ST
Mailing Address - Street 2:
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-2451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:262 S WATER ST
Practice Address - Street 2:
Practice Address - City:KITTANNING
Practice Address - State:PA
Practice Address - Zip Code:16201-2451
Practice Address - Country:US
Practice Address - Phone:724-545-7350
Practice Address - Fax:724-545-7352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP413839L333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011831570001Medicaid
3959333OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3959333OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3959333OtherOTHER ID NUMBER-COMMERCIAL NUMBER