Provider Demographics
NPI:1255514691
Name:WARREN MS LLC
Entity type:Organization
Organization Name:WARREN MS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-726-3741
Mailing Address - Street 1:3 PENNSYLVANIA AVE E
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2526
Mailing Address - Country:US
Mailing Address - Phone:814-726-3741
Mailing Address - Fax:
Practice Address - Street 1:3 PENNSYLVANIA AVE E
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2526
Practice Address - Country:US
Practice Address - Phone:814-726-3741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020774830001Medicaid
PA3989475OtherNCPDP #
PA3989475OtherNCPDP #
PA6098510001Medicare NSC
PA3989475OtherNCPDP #