MEDICARE: SOVEREIGN COVENANT PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	PP410348L	PA
2	333600000X	Pharmacy	PP410348L	PA
3	3336C0003X	Community/Retail Pharmacy	PP410348L	PA

General Provider Information

NPI Number	:	1477556363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOVEREIGN COVENANT PHARMACY LLC

Provider Business Mailing Address
First Line	:	145 N ANTRIM WAY
Second Line	:
City	:	GREENCASTLE
State	:	PA
Zip	:	17225-1403
Country	:	US
Telephone Number	:	717-597-2426
Fax Number	:	717-597-3705

Provider Business Practice Location Address
First Line	:	145 N ANTRIM WAY
Second Line	:
City	:	GREENCASTLE
State	:	PA
Zip	:	17225-1403
Country	:	US
Telephone Number	:	717-597-2426
Fax Number	:	717-597-3705

Authorized Official
Title or Position	:	OWNER
Name	:	MR. WAYNE G MYERS
Credential	:	RPH
Telephone Number	:	717-597-2426

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	01/26/2024

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