Provider Demographics
NPI:1669414371
Name:OLDE HICKORY PHARMACY INC
Entity type:Organization
Organization Name:OLDE HICKORY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO HEAD PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:BON FESSUTO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:717-824-2189
Mailing Address - Street 1:3 WOODHENGE CIR
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-9096
Mailing Address - Country:US
Mailing Address - Phone:717-824-2189
Mailing Address - Fax:717-569-3807
Practice Address - Street 1:3 WOODHENGE CIR
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-9096
Practice Address - Country:US
Practice Address - Phone:717-431-8429
Practice Address - Fax:717-569-3807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP413656L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3960526OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PA1205719Medicaid