Healthcare Provider Details

I. General information

NPI: 1144631102
Provider Name (Legal Business Name): EAST BROWN STREET PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 N COURTLAND ST SUITE 2
EAST STROUDSBURG PA
18301-1930
US

IV. Provider business mailing address

364 N COURTLAND ST SUITE 2
EAST STROUDSBURG PA
18301-1930
US

V. Phone/Fax

Practice location:
  • Phone: 570-369-5833
  • Fax: 570-872-9888
Mailing address:
  • Phone: 570-369-5833
  • Fax: 570-872-9888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPP482449
License Number StatePA

VIII. Authorized Official

Name: RIYADH A ABDUL
Title or Position: ORGANIZATION OFFICER
Credential:
Phone: 570-872-9800