Provider Demographics
NPI:1699708768
Name:NORLAND AVENUE PHARMACY, LLC
Entity type:Organization
Organization Name:NORLAND AVENUE PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:717-217-6793
Mailing Address - Street 1:12 ST. PAUL DRIVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4230
Mailing Address - Country:US
Mailing Address - Phone:717-217-6790
Mailing Address - Fax:
Practice Address - Street 1:12 ST. PAUL DRIVE
Practice Address - Street 2:SUITE 105
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-4230
Practice Address - Country:US
Practice Address - Phone:717-217-6790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP415735L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018271470001Medicaid
PA4029600001OtherPTAN