Healthcare Provider Details

I. General information

NPI: 1386633709
Provider Name (Legal Business Name): HAZLE DRUGS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E BROAD ST
HAZLETON PA
18201-6520
US

IV. Provider business mailing address

1 E BROAD ST
HAZLETON PA
18201-6520
US

V. Phone/Fax

Practice location:
  • Phone: 570-454-2476
  • Fax: 570-454-4532
Mailing address:
  • Phone:
  • Fax:

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 Code333600000X
TaxonomyPharmacy
License NumberPP411007L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1007606540004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier3918173
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER

VIII. Authorized Official

Name: WILLIAM SPEAR
Title or Position: PRESIDENT
Credential:
Phone: 570-454-2476