Provider Demographics
NPI:1699247031
Name:JAMES DRUG STORE - MARTINSBURG
Entity type:Organization
Organization Name:JAMES DRUG STORE - MARTINSBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:DELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-419-7800
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:LORETTO
Mailing Address - State:PA
Mailing Address - Zip Code:15940-0086
Mailing Address - Country:US
Mailing Address - Phone:814-419-7800
Mailing Address - Fax:814-419-8534
Practice Address - Street 1:2423 BETTS AVE INSIDE KEN'S BILO
Practice Address - Street 2:
Practice Address - City:NORTHERN CAMBRIA
Practice Address - State:PA
Practice Address - Zip Code:15714
Practice Address - Country:US
Practice Address - Phone:814-420-8551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JAMES DRUG STORE MARTINSBURG INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034859190001Medicaid