Healthcare Provider Details

I. General information

NPI: 1184210056
Provider Name (Legal Business Name): JONATHAN P DEBALKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 S HANCOCK ST
MCADOO PA
18237-1608
US

IV. Provider business mailing address

322 S HANCOCK ST
MCADOO PA
18237-1608
US

V. Phone/Fax

Practice location:
  • Phone: 570-929-1130
  • Fax: 570-929-1208
Mailing address:
  • Phone: 570-929-1130
  • Fax: 570-929-1208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP441786
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: