Provider Demographics
NPI:1356424709
Name:BURRELL PHARMACY INC
Entity type:Organization
Organization Name:BURRELL PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MICKLOW
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-845-1184
Mailing Address - Street 1:111 2ND ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEECHBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15656-1326
Mailing Address - Country:US
Mailing Address - Phone:724-845-1184
Mailing Address - Fax:724-842-2071
Practice Address - Street 1:111 2ND ST
Practice Address - Street 2:
Practice Address - City:LEECHBURG
Practice Address - State:PA
Practice Address - Zip Code:15656-1326
Practice Address - Country:US
Practice Address - Phone:724-845-1184
Practice Address - Fax:724-842-2071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP414776L3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007627200003Medicaid
PA3967215OtherNCPDP
PA1007627200003Medicaid