Provider Demographics
NPI:1669900932
Name:CLAYSVILLE PHARMACY LLC
Entity type:Organization
Organization Name:CLAYSVILLE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERICH
Authorized Official - Middle Name:
Authorized Official - Last Name:CUSHEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-663-7707
Mailing Address - Street 1:802 VANDERBILT RD
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-6241
Mailing Address - Country:US
Mailing Address - Phone:724-626-1091
Mailing Address - Fax:724-626-0162
Practice Address - Street 1:802 VANDERBILT RD
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-6241
Practice Address - Country:US
Practice Address - Phone:724-626-1091
Practice Address - Fax:724-626-0162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
PAPP412619L3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2169336OtherPK
PA1024774490002Medicaid
5159170009Medicare NSC