Provider Demographics
NPI:1982091468
Name:MAXI DRUG SOUTH LP
Entity Type:Organization
Organization Name:MAXI DRUG SOUTH LP
Other - Org Name:RITE AID PHARMACY 06727
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR MA NAGER PROVIDER ENROLLMENT
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 CMNS
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:717-975-5937
Mailing Address - Fax:717-975-8659
Practice Address - Street 1:500 BROAD STREET
Practice Address - Street 2:UNIT 6
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02927-1234
Practice Address - Country:US
Practice Address - Phone:401-868-9070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4107771OtherNABP
RINM00221Medicaid
RINM00221Medicaid
RIP00972632Medicare PIN
RI739006369Medicare PIN