Healthcare Provider Details

I. General information

NPI: 1609948496
Provider Name (Legal Business Name): MICHAEL J BRISLIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 PRESCOTT AVE
SCRANTON PA
18510-1411
US

IV. Provider business mailing address

953 PRESCOTT AVE
SCRANTON PA
18510-1411
US

V. Phone/Fax

Practice location:
  • Phone: 570-346-2935
  • Fax: 570-207-4767
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPP413264L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier0008873920002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier3945079
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER-COMMERCIAL NUMBER

VIII. Authorized Official

Name: MICHAEL BRISLIN
Title or Position: OWNER PHARMACIST
Credential: RPH
Phone: 570-346-2935