Provider Demographics
NPI:1558986687
Name:CLAYSVILLE PHARMACY, LLC
Entity type:Organization
Organization Name:CLAYSVILLE PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:MIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-633-7707
Mailing Address - Street 1:305 MAIN ST BOX K
Mailing Address - Street 2:
Mailing Address - City:CLAYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15323-3300
Mailing Address - Country:US
Mailing Address - Phone:724-663-7077
Mailing Address - Fax:
Practice Address - Street 1:305 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLAYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15323-3300
Practice Address - Country:US
Practice Address - Phone:724-663-7707
Practice Address - Fax:724-663-5994
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLAYSVILLE PHARMACY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-15
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016973030001Medicaid