Provider Demographics
NPI:1124352760
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 1:1049 SHOEMAKER ST STE 2
Mailing Address - Street 2:
Mailing Address - City:NANTY GLO
Mailing Address - State:PA
Mailing Address - Zip Code:15943-1248
Mailing Address - Country:US
Mailing Address - Phone:814-736-3044
Mailing Address - Fax:814-736-9522
Practice Address - Street 1:1049 SHOEMAKER ST STE 2
Practice Address - Street 2:
Practice Address - City:NANTY GLO
Practice Address - State:PA
Practice Address - Zip Code:15943-1248
Practice Address - Country:US
Practice Address - Phone:814-736-3044
Practice Address - Fax:814-736-9522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4818583336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPP481858OtherPA STATE LICENSE