Provider Demographics
NPI:1336403773
Name:PENNSCARERX PHARMA INC
Entity Type:Organization
Organization Name:PENNSCARERX PHARMA INC
Other - Org Name:PENNSCARE FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:YADAGIRI
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-972-3340
Mailing Address - Street 1:182 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PENNSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08070-1419
Mailing Address - Country:US
Mailing Address - Phone:856-514-2638
Mailing Address - Fax:856-514-2678
Practice Address - Street 1:182 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-1419
Practice Address - Country:US
Practice Address - Phone:856-514-2638
Practice Address - Fax:856-514-2678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-29
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007204003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136131OtherPK
NJ0383929Medicaid