Provider Demographics
NPI:1407949852
Name:HERMITAGE PHARMACY LLC
Entity type:Organization
Organization Name:HERMITAGE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRETTON
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:WALBERG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-612-2131
Mailing Address - Street 1:30 CONNEAUT LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-2167
Mailing Address - Country:US
Mailing Address - Phone:724-612-2131
Mailing Address - Fax:724-983-0918
Practice Address - Street 1:1740 E STATE ST
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-1862
Practice Address - Country:US
Practice Address - Phone:724-983-8451
Practice Address - Fax:724-983-0918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 332B00000X, 3336S0011X
PAPP412447L3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104547785-0001Medicaid
2083437OtherPK
PA1023278440002Medicaid
2083437OtherPK
PA0010800060001Medicaid