Provider Demographics
NPI:1104954916
Name:NORTHEAST PHARMACY SERVICES, INC.
Entity type:Organization
Organization Name:NORTHEAST PHARMACY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-377-9730
Mailing Address - Street 1:590 COAL STREET
Mailing Address - Street 2:
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-1339
Mailing Address - Country:US
Mailing Address - Phone:610-377-9730
Mailing Address - Fax:610-377-9510
Practice Address - Street 1:590 COAL STREET
Practice Address - Street 2:
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-1339
Practice Address - Country:US
Practice Address - Phone:610-377-9730
Practice Address - Fax:610-377-9510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP415689L3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018207070001Medicaid
PA0018207070001Medicaid