Provider Demographics
NPI:1992920805
Name:MIKES APOTHECARY INC
Entity type:Organization
Organization Name:MIKES APOTHECARY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:FORNATARO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-658-4557
Mailing Address - Street 1:708 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-4137
Mailing Address - Country:US
Mailing Address - Phone:724-658-4557
Mailing Address - Fax:724-658-4547
Practice Address - Street 1:708 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101-4137
Practice Address - Country:US
Practice Address - Phone:724-658-4557
Practice Address - Fax:724-658-4547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410825L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022164700001Medicaid
PA1022164700001Medicaid