Healthcare Provider Details

I. General information

NPI: 1063465383
Provider Name (Legal Business Name): DEBALKOS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/04/2012
Certification Date:
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 TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPP412373L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPP412373L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier237105
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerPA BS DME
# 2
Identifier39HA85
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAPITAL BC DME
# 3
Identifier001017817
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: DR. JOHN NICHOLAS DEBALKO
Title or Position: PRESIDENT
Credential: RPH PHARMD
Phone: 570-929-2028