Healthcare Provider Details

I. General information

NPI: 1841645462
Provider Name (Legal Business Name): SKIPPACK RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4118 W SKIPPACK PIKE
SKIPPACK PA
19474
US

IV. Provider business mailing address

4118 W SKIPPACK PIKE PO BOX 797
SKIPPACK PA
19474
US

V. Phone/Fax

Practice location:
  • Phone: 610-584-6544
  • Fax: 610-584-4271
Mailing address:
  • Phone: 610-584-6544
  • Fax: 610-584-4271

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 NumberPP412308L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier103221699-0001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier2159578
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: ANITHA RAO MANDAVA
Title or Position: PHARMACY MANAGER
Credential:
Phone: 610-584-6544