Healthcare Provider Details

I. General information

NPI: 1669823266
Provider Name (Legal Business Name): PERIGON PHARMACY 360, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 STEVENSON MILL RD STE 200
CORAOPOLIS PA
15108-2446
US

IV. Provider business mailing address

1120 STEVENSON MILL RD STE 200
CORAOPOLIS PA
15108-2446
US

V. Phone/Fax

Practice location:
  • Phone: 412-684-2500
  • Fax: 844-582-5332
Mailing address:
  • Phone: 844-698-2533
  • Fax: 844-582-5332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1032363790001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier1669823266
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 3
Identifier1689851
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 4
Identifier7P2679
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 5
Identifier564121700
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer
# 6
Identifier2111445
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 7
Identifier2160783
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 8
Identifier656739
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: GENESE MARIE HENDRICKSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 412-684-2500