=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316968993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAYETTE FOODS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3239 WASHINGTON PIKE
-----------------------------------------------------
City | BRIDGEVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15017-1460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-914-0752
-----------------------------------------------------
Fax | 412-914-0749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 188
-----------------------------------------------------
City | BRIDGEVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15017-0188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-914-0752
-----------------------------------------------------
Fax | 412-914-0749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | LIZ L HOSKINS
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 412-914-0752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP415545
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------