Provider Demographics
NPI:1316131881
Name:SUSQUEHANNA HEALTH PHARMACY
Entity type:Organization
Organization Name:SUSQUEHANNA HEALTH PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:C
Authorized Official - Last Name:YOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-321-3175
Mailing Address - Street 1:PO BOX 642464
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15264-2464
Mailing Address - Country:US
Mailing Address - Phone:412-328-4788
Mailing Address - Fax:
Practice Address - Street 1:740 HIGH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3102
Practice Address - Country:US
Practice Address - Phone:570-321-2818
Practice Address - Fax:570-321-2819
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UPMC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-28
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0004X
PAPP4816873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2082029OtherPK
PA0014334830005Medicaid