=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427109883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROGER J. FEURA BRADFORD PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2007
-----------------------------------------------------
Last Update Date | 07/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 MAIN STREET
-----------------------------------------------------
City | BRADFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16701-2019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-362-6521
-----------------------------------------------------
Fax | 814-362-3593
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 MAIN STREET
-----------------------------------------------------
City | BRADFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16701-2019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-362-6521
-----------------------------------------------------
Fax | 814-362-3593
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHARMACIST
-----------------------------------------------------
Name | MR. ROGER J FEURA
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 814-362-6521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP413546L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------