Provider Demographics
NPI:1063509941
Name:CONCORDVILLE PHARMACY INC
Entity type:Organization
Organization Name:CONCORDVILLE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLURA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:610-459-2424
Mailing Address - Street 1:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:CONCORDVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19331-0465
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:790 E BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:CONCORDVILLE
Practice Address - State:PA
Practice Address - Zip Code:19331
Practice Address - Country:US
Practice Address - Phone:610-459-2424
Practice Address - Fax:610-558-9856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4813233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3982623OtherOTHER ID NUMBER
PA1008867900001Medicaid
3982623OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3982623OtherOTHER ID NUMBER