Provider Demographics
NPI:1811084031
Name:ALTOONA UNION AVENUE PHARMACY
Entity type:Organization
Organization Name:ALTOONA UNION AVENUE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:EARNEST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-944-2095
Mailing Address - Street 1:2411 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-2105
Mailing Address - Country:US
Mailing Address - Phone:814-944-2095
Mailing Address - Fax:814-949-9575
Practice Address - Street 1:2411 8TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2105
Practice Address - Country:US
Practice Address - Phone:814-944-2095
Practice Address - Fax:814-949-9575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410789L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3944623OtherNCPDP #
PA0009967710002Medicaid
PAAT8068416OtherDEA #
PA0009967710002Medicaid