Provider Demographics
NPI:1316968993
Name:FAYETTE FOODS, LLC
Entity type:Organization
Organization Name:FAYETTE FOODS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOSKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:412-914-0752
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15017-0188
Mailing Address - Country:US
Mailing Address - Phone:412-914-0752
Mailing Address - Fax:412-914-0749
Practice Address - Street 1:3239 WASHINGTON PIKE
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15017-1460
Practice Address - Country:US
Practice Address - Phone:412-914-0752
Practice Address - Fax:412-914-0749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4155453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001800591001Medicaid
PAPP415545OtherPA STATE PHARMACY PERMIT
3976430OtherNCPDP
3976430OtherNCPDP