Provider Demographics
NPI:1295888162
Name:MARY BETH MARCOLINE
Entity type:Organization
Organization Name:MARY BETH MARCOLINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCOLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-254-4363
Mailing Address - Street 1:530 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CLYMER
Mailing Address - State:PA
Mailing Address - Zip Code:15728-1183
Mailing Address - Country:US
Mailing Address - Phone:724-254-4363
Mailing Address - Fax:724-254-1390
Practice Address - Street 1:530 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CLYMER
Practice Address - State:PA
Practice Address - Zip Code:15728-1183
Practice Address - Country:US
Practice Address - Phone:724-254-4363
Practice Address - Fax:724-254-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1204874Medicaid
PA1204874Medicaid
PA0174810001Medicare NSC