Provider Demographics
NPI:1265615603
Name:TITUSVILLE MS LLC
Entity type:Organization
Organization Name:TITUSVILLE 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:814-827-1849
Mailing Address - Street 1:329 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-1642
Mailing Address - Country:US
Mailing Address - Phone:814-827-1849
Mailing Address - Fax:814-827-0220
Practice Address - Street 1:329 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-1642
Practice Address - Country:US
Practice Address - Phone:814-827-1849
Practice Address - Fax:814-827-0220
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
PA1020774380001Medicaid
PA3989487OtherNCPDP #
PA3989487OtherNCPDP #
PA1020774380001Medicaid
PA6098260001Medicare NSC