Healthcare Provider Details

I. General information

NPI: 1407949852
Provider Name (Legal Business Name): HERMITAGE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 E STATE ST
HERMITAGE PA
16148-1862
US

IV. Provider business mailing address

30 CONNEAUT LAKE ROAD
GREENVILLE PA
16125-2167
US

V. Phone/Fax

Practice location:
  • Phone: 724-983-8451
  • Fax: 724-983-0918
Mailing address:
  • Phone: 724-612-2131
  • Fax: 724-983-0918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP412447L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BRETTON CLARK WALBERG
Title or Position: MEMBER
Credential: RPH
Phone: 724-612-2131