=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720358344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEPIETROS PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2012
-----------------------------------------------------
Last Update Date | 10/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 617 3RD ST
-----------------------------------------------------
City | DUNMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18512-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-209-7440
-----------------------------------------------------
Fax | 570-209-7442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 617 3RD ST
-----------------------------------------------------
City | DUNMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18512-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-209-7440
-----------------------------------------------------
Fax | 570-209-7442
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER/OWNER
-----------------------------------------------------
Name | THOMAS DEPIETRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-209-7440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP482235
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------