Provider Demographics
NPI:1184787889
Name:CHESTNUT RIDGE PHARMACY LLC
Entity type:Organization
Organization Name:CHESTNUT RIDGE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WAUGERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-839-9950
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:FISHERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15539-0095
Mailing Address - Country:US
Mailing Address - Phone:814-839-9950
Mailing Address - Fax:814-839-9952
Practice Address - Street 1:2262 QUAKER VALLEY RD
Practice Address - Street 2:
Practice Address - City:FISHERTOWN
Practice Address - State:PA
Practice Address - Zip Code:15539
Practice Address - Country:US
Practice Address - Phone:814-839-9950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4811723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01917280Medicaid
PA4593800001Medicare ID - Type Unspecified