=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609470749
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARA LYNNE GREVERA RPH BCMTMS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2020
-----------------------------------------------------
Last Update Date | 11/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 WILKES BARRE TOWNSHIP CMNS
-----------------------------------------------------
City | WILKES BARRE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18702-6846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-829-4983
-----------------------------------------------------
Fax | 570-793-2367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3303 CHASE RD
-----------------------------------------------------
City | SHAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18708-9425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP040608L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------