Healthcare Provider Details

I. General information

NPI: 1295814978
Provider Name (Legal Business Name): LANDIS SUPER MARKET INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2685 COUNTY LINE RD
TELFORD PA
18969-1075
US

IV. Provider business mailing address

2685 COUNTY LINE RD
TELFORD PA
18969-1075
US

V. Phone/Fax

Practice location:
  • Phone: 215-723-2302
  • Fax: 215-723-3144
Mailing address:
  • Phone: 877-540-4748
  • Fax: 801-716-4872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP481083
License Number StatePA

VIII. Authorized Official

Name: ROBERT KILLORAN
Title or Position: PIC/PHARMACY MANAGER
Credential: B.S.P
Phone: 717-919-8936