Healthcare Provider Details

I. General information

NPI: 1407314883
Provider Name (Legal Business Name): JOHN R SLAGLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LIBERTY ST
CLARION PA
16214-1808
US

IV. Provider business mailing address

100 LIBERTY ST
CLARION PA
16214-1808
US

V. Phone/Fax

Practice location:
  • Phone: 814-226-9310
  • Fax:
Mailing address:
  • Phone: 814-226-9310
  • Fax: 814-226-9329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100772724210005
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: JOHN R SLAGLE
Title or Position: OWNER
Credential:
Phone: 814-226-9310