MEDICARE: MAXI DRUG SOUTH LP

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
2	3336C0003X	Community/Retail Pharmacy	PHA00306	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4105183	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1780783159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAXI DRUG SOUTH LP

Provider Business Mailing Address
First Line	:	200 NEWBERRY COMMONS
Second Line	:
City	:	ETTERS
State	:	PA
Zip	:	17319-9363
Country	:	US
Telephone Number	:	717-761-2633
Fax Number	:	717-975-8659

Provider Business Practice Location Address
First Line	:	3034 EAST MAIN ROAD
Second Line	:
City	:	PORTSMOUTH
State	:	RI
Zip	:	02871-4205
Country	:	US
Telephone Number	:	401-683-1270
Fax Number	:

Authorized Official
Title or Position	:	MANAGER ONLINE ADJUDICATION
Name	:	JENNIFER ZOREK
Credential	:
Telephone Number	:	717-975-5937

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	12/13/2011

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