=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760114904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRAGONFLY HOSPICE PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2022
-----------------------------------------------------
Last Update Date | 06/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1710 UNDERPASS WAY STE 301
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21740-6975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-358-7220
-----------------------------------------------------
Fax | 833-734-1175
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 264 SMITH TOWNSHIP STATE RD STE 5
-----------------------------------------------------
City | BURGETTSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15021-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-414-1425
-----------------------------------------------------
Fax | 855-445-4203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP PHARMACY SERVICES
-----------------------------------------------------
Name | DR. MICHELLE J MIKUS
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 412-403-4301
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------