Provider Demographics
NPI:1285768994
Name:GUARDIAN LONG TERM CARE PHARMACY INC
Entity type:Organization
Organization Name:GUARDIAN LONG TERM CARE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RENDOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-503-7400
Mailing Address - Street 1:123 BRUBAKER RD
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15824-2505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:147 OLD NEWPORT ST
Practice Address - Street 2:STE 1
Practice Address - City:NANTICOKE
Practice Address - State:PA
Practice Address - Zip Code:18634-1327
Practice Address - Country:US
Practice Address - Phone:570-812-0300
Practice Address - Fax:570-812-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4816613336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015064750002Medicaid
3988079OtherOTHER ID NUMBER
3988079OtherOTHER ID NUMBER-COMMERCIAL NUMBER