Healthcare Provider Details

I. General information

NPI: 1295807329
Provider Name (Legal Business Name): COSTA DRUGS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 PROSPECT AVE
SCRANTON PA
18505-2772
US

IV. Provider business mailing address

609 PROSPECT AVE
SCRANTON PA
18505-2772
US

V. Phone/Fax

Practice location:
  • Phone: 570-961-1168
  • Fax: 570-207-4633
Mailing address:
  • Phone: 570-961-1168
  • Fax: 570-207-4633

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 NumberPP410487L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1007612680003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier2078775
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: GEORGE CHELLAND
Title or Position: CORP SEC
Credential: RPH
Phone: 570-961-1168