Healthcare Provider Details

I. General information

NPI: 1184993040
Provider Name (Legal Business Name): MAINLINE PHARMACY EBENSBURG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 NEW GERMANY RD
EBENSBURG PA
15931-1862
US

IV. Provider business mailing address

1207 SECOND STREET
CRESSON PA
16630-0058
US

V. Phone/Fax

Practice location:
  • Phone: 814-472-9390
  • Fax: 814-472-1166
Mailing address:
  • Phone: 814-408-6800
  • Fax: 814-886-2203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP412694L
License Number StatePA

VIII. Authorized Official

Name: STEVEN JOSEPH DECRISCIO
Title or Position: CFO
Credential:
Phone: 814-408-6800