Basic Information
Provider Information | |||||||||
NPI: | 1891965661 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MILLCREEK COMMUNITY HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MILLCREEK COMM HOSP PHARMACY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5515 PEACH ST | ||||||||
Address2: |   | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165092603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8148644031 | ||||||||
FaxNumber: | 8148687770 | ||||||||
Practice Location | |||||||||
Address1: | 5515 PEACH ST | ||||||||
Address2: |   | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165092603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8148644031 | ||||||||
FaxNumber: | 8148687770 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2008 | ||||||||
LastUpdateDate: | 03/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HELLER | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8148687758 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | HP418064L | PA | Y |   | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
ID | Type | State | Issuer | Description | HP418064L | 01 | PA | PA LICENSE | OTHER |