Healthcare Provider Details

I. General information

NPI: 1235245903
Provider Name (Legal Business Name): CAPITANO'S PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S MAIN ST
OLD FORGE PA
18518-1600
US

IV. Provider business mailing address

101 S MAIN ST
OLD FORGE PA
18518-1600
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-5450
  • Fax: 570-457-1190
Mailing address:
  • Phone: 570-457-5450
  • Fax: 570-457-1190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP414814L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier001431934-0001-24
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. PETER JAY CAPITANO
Title or Position: PHARMACIST/OWNER
Credential: RPH
Phone: 570-457-5450