Provider Demographics
NPI:1750380564
Name:KRESGE LEBAR PHARMACY
Entity type:Organization
Organization Name:KRESGE LEBAR PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:STORE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTINS
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICKISIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-421-0710
Mailing Address - Street 1:425 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-2462
Mailing Address - Country:US
Mailing Address - Phone:570-421-0710
Mailing Address - Fax:570-421-3405
Practice Address - Street 1:425 MAIN ST
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-2462
Practice Address - Country:US
Practice Address - Phone:570-421-0710
Practice Address - Fax:570-421-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP411345L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011208930001Medicaid
5226210001Medicare ID - Type Unspecified