Healthcare Provider Details

I. General information

NPI: 1871674028
Provider Name (Legal Business Name): ANDREW BROWN'S DRUG STORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1789 N KEYSER AVE SUITE 2
SCRANTON PA
18508-1250
US

IV. Provider business mailing address

1502 PITTSTON AVE
SCRANTON PA
18505-1668
US

V. Phone/Fax

Practice location:
  • Phone: 570-558-9618
  • Fax: 570-558-9686
Mailing address:
  • Phone: 570-343-2442
  • Fax: 570-346-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number6000006622
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0005764360004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. ROBERT F BROWN JR.
Title or Position: VP OPERATIONS
Credential: MHA
Phone: 570-343-2442