Provider Demographics
NPI:1316952948
Name:GUARDIAN HEALTHCARE PHARMACY, LLC
Entity type:Organization
Organization Name:GUARDIAN HEALTHCARE PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:VARACALLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:888-503-7474
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:888-503-7474
Mailing Address - Fax:877-371-5677
Practice Address - Street 1:123 BRUBAKER RD
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:PA
Practice Address - Zip Code:15824-2505
Practice Address - Country:US
Practice Address - Phone:888-503-7474
Practice Address - Fax:877-371-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X
PAPP4815233336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015064750001Medicaid
OH02163160000014708Medicaid
2087733OtherPK
PA1015064750001Medicaid
5558500001Medicare NSC