=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609917731
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEWARTS DRUG STORE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 219 W MAHONING ST
-----------------------------------------------------
City | PUNXSUTAWNEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15767-1918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-938-8570
-----------------------------------------------------
Fax | 814-938-4644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 219 W MAHONING ST
-----------------------------------------------------
City | PUNXSUTAWNEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15767-1918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-938-8570
-----------------------------------------------------
Fax | 814-938-4644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRADLEY JAMES GIGLIOTTI
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 814-938-8570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP412408L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------