Provider Demographics
NPI:1245366137
Name:CENTRE CREST PHARMACY
Entity type:Organization
Organization Name:CENTRE CREST PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUCKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-355-6890
Mailing Address - Street 1:502 E HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTE
Mailing Address - State:PA
Mailing Address - Zip Code:16823-2128
Mailing Address - Country:US
Mailing Address - Phone:814-355-6890
Mailing Address - Fax:814-355-6999
Practice Address - Street 1:502 E HOWARD ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTE
Practice Address - State:PA
Practice Address - Zip Code:16823-2128
Practice Address - Country:US
Practice Address - Phone:814-355-6890
Practice Address - Fax:814-355-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAHP416574-L3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007296630006Medicaid
PAHP416574-LOtherSTATE LICENSE NUMBER