Healthcare Provider Details

I. General information

NPI: 1770944662
Provider Name (Legal Business Name): ELAINE COUTROS BLONDEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 DRINKER TPKE
COVINGTON TOWNSHIP PA
18444-7947
US

IV. Provider business mailing address

302 HILLSIDE DR
MOSCOW PA
18444-8624
US

V. Phone/Fax

Practice location:
  • Phone: 570-842-7848
  • Fax:
Mailing address:
  • Phone: 570-650-6306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP032788L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRI01689000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: