Provider Demographics
NPI:1386723054
Name:SALEM CROSSROADS APOTHECARY LLC
Entity type:Organization
Organization Name:SALEM CROSSROADS APOTHECARY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KIESEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-468-5565
Mailing Address - Street 1:195 SHEFFIELD DR STE B
Mailing Address - Street 2:
Mailing Address - City:DELMONT
Mailing Address - State:PA
Mailing Address - Zip Code:15626-1744
Mailing Address - Country:US
Mailing Address - Phone:724-468-5565
Mailing Address - Fax:724-468-8336
Practice Address - Street 1:195 SHEFFIELD DR STE B
Practice Address - Street 2:
Practice Address - City:DELMONT
Practice Address - State:PA
Practice Address - Zip Code:15626-1744
Practice Address - Country:US
Practice Address - Phone:724-468-5565
Practice Address - Fax:724-468-8336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP410636L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1042405450001Medicaid
2082625OtherPK
PA1007287000004Medicaid