Healthcare Provider Details

I. General information

NPI: 1134159536
Provider Name (Legal Business Name): CLAYSVILLE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MAIN ST
CLAYSVILLE PA
15323-3300
US

IV. Provider business mailing address

305 MAIN ST
CLAYSVILLE PA
15323-3300
US

V. Phone/Fax

Practice location:
  • Phone: 724-663-7707
  • Fax: 724-663-5994
Mailing address:
  • Phone: 724-663-7707
  • Fax: 724-663-5994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP410513L
License Number StatePA

VIII. Authorized Official

Name: ERICH CUSHEY
Title or Position: OWNER
Credential: RPH
Phone: 724-663-7707