Provider Demographics
NPI:1932430998
Name:LLEWELLYN'S LTC
Entity Type:Organization
Organization Name:LLEWELLYN'S LTC
Other - Org Name:LLEWELLYN'S INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DESANTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-457-2221
Mailing Address - Street 1:703 B MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:PA
Mailing Address - Zip Code:18641
Mailing Address - Country:US
Mailing Address - Phone:570-457-2221
Mailing Address - Fax:570-457-3224
Practice Address - Street 1:703B MAIN ST
Practice Address - Street 2:
Practice Address - City:AVOCA
Practice Address - State:PA
Practice Address - Zip Code:18641
Practice Address - Country:US
Practice Address - Phone:570-237-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LLEWELLYNS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-14
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
PAPP411400L3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017030320001Medicaid