Provider Demographics
NPI:1912920455
Name:PERRY DRUG STORES INC AND SUBSIDIARIES
Entity Type:Organization
Organization Name:PERRY DRUG STORES INC AND SUBSIDIARIES
Other - Org Name:RITE AID PHARMACY 04389
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER ONLINE ADJUDICATION
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-975-5937
Mailing Address - Street 1:200 NEWBERRY COMMONS
Mailing Address - Street 2:
Mailing Address - City:ETTERS
Mailing Address - State:PA
Mailing Address - Zip Code:17319-9363
Mailing Address - Country:US
Mailing Address - Phone:717-761-2633
Mailing Address - Fax:717-975-8659
Practice Address - Street 1:43034 DEQUINDRE ROAD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1722
Practice Address - Country:US
Practice Address - Phone:586-254-1021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MI59363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2351891OtherOTHER ID NUMBER
MI2351891Medicaid
0694660102Medicare NSC
MI0P17240Medicare PIN
MIP00460010Medicare PIN