Healthcare Provider Details

I. General information

NPI: 1154410884
Provider Name (Legal Business Name): RITE AID OF PENNSYLVANIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NORTH WASHINGTON AVENUE
SCRANTON PA
18503-1503
US

IV. Provider business mailing address

200 NEWBERRY COMMONS
ETTERS PA
17319-9363
US

V. Phone/Fax

Practice location:
  • Phone: 570-343-7301
  • Fax:
Mailing address:
  • Phone: 717-761-2633
  • Fax: 717-975-8659

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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP412089L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier3908324
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER
# 2
Identifier1007292980909
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMEDICAID DME
# 3
Identifier1007292980909
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: JENNIFER ZOREK
Title or Position: MANAGER ONLINE ADJUDICATION
Credential:
Phone: 717-975-5937