Provider Demographics
NPI:1124117312
Name:MAINLINE CPL, LLC
Entity type:Organization
Organization Name:MAINLINE CPL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DECRISCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-408-6800
Mailing Address - Street 1:1207 SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:CRESSON
Mailing Address - State:PA
Mailing Address - Zip Code:16630-1147
Mailing Address - Country:US
Mailing Address - Phone:814-886-5667
Mailing Address - Fax:814-886-2203
Practice Address - Street 1:1207 SECOND STREET
Practice Address - Street 2:
Practice Address - City:CRESSON
Practice Address - State:PA
Practice Address - Zip Code:16630-1147
Practice Address - Country:US
Practice Address - Phone:814-886-5667
Practice Address - Fax:814-886-2203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP412243L333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007331830003Medicaid
PA1194730001Medicare ID - Type Unspecified