Provider Demographics
NPI:1851476949
Name:BRACEY'S MOUNT POCONO, INC.
Entity type:Organization
Organization Name:BRACEY'S MOUNT POCONO, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8439
Mailing Address - Street 1:921 DRINKER TPKE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18444-7947
Mailing Address - Country:US
Mailing Address - Phone:570-842-7461
Mailing Address - Fax:570-842-6520
Practice Address - Street 1:89 STATE ROUTE 940
Practice Address - Street 2:
Practice Address - City:MOUNT POCONO
Practice Address - State:PA
Practice Address - Zip Code:18344-1426
Practice Address - Country:US
Practice Address - Phone:570-839-5340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4813733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009983850001Medicaid
3983233OtherNCPDP
PA1009983850001Medicaid